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幸福感及其對健康的可能影響-以廣建理論層面而言

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(1)國立臺灣師範大學健康促進與衛生教育學系 博士論文. 指導教授:李思賢博士. 幸福感及其對健康的可能影響以廣建理論層面而言 Happiness and Its Possible Influence on Health:. An Aspect of the Broaden and Build Theory. 研 究 生:江慧珣 撰 中 華 民 國 102 年 6 月.

(2) Abstract Purpose: A growing awareness of the rapidly-increasing aged population in the world has led to growing attention on mental health promotion in late life. The aims of this dissertation are to determine the components of happiness among retired old adults and to examine the influence of happiness on their health. Method: This dissertation includes 3 interrelated studies. Both quantitative and qualitative research methods were applied. Study 1 examines the validity and reliability of the Chinese Happiness Inventory. Study 2 investigates the relationships between happiness and physical, psychological and social factors, as well as the influence of happiness on these three factors. Study 3 evaluates the process of happiness promotion and its impact on health. Exploratory factor analysis was performed to analyze the components of the Chinese Happiness Inventory, and a canonical correlation analysis was applied to explore the correlation with Ryff's psychological well-being scales. A path analysis was applied to examine the relationships among happiness and physical, psychological and social factors, and the content analysis was applied to interpret the qualitative results. Results: The results indicate that the Chinese Happiness Inventory includes 3 components: positive affect, life satisfaction and interpersonal relationships. These components were highly-correlated with self-acceptance, positive relations with others, environmental mastery, purpose in life, and personal growth. Happiness was also positively-correlated with perceived health, sense of coherence and family relationships. From the path model, happiness has a direct influence on perceived health contributions by family relationships and sense of coherence. The family relationships influence happiness directly and indirectly by furnishing a sense of coherence. The qualitative analysis showed that when individuals build higher levels of happiness through positive broadening of their social connections, this results in positive family relationships and a good sense of coherence. Conclusions: The study found that happiness has a positive impact on health and that happiness is promoted by good family relationships and a sense of coherence. Consequently, promotion of positive social connection and positive experience sharing may benefit family relationships and a sense of coherence, providing further higher levels of happiness and good health among retired older adults. Key word: Happiness, Sense of coherence, Family relationships, Health -i-.

(3) Attestation I understand the nature of plagiarism, and I am aware of the University’s policy on this. I certify that this dissertation reports original work by me during my University project except for the following: 1. The quantitative data analyzed in this dissertation and participants of qualitative interviews were a part of a Dr. Tony Szu-Hsien Lee’s project entitled ‘Gender differences and influence of walking exercise and a psychosocial intervention on psychological well-being and sense of coherence amongst retired senior citizens’. 2. The reliability and validity of constructs of Happiness and PWB in Literature Review, Section 4.2 and related discussions in Section 5 were drafted by me and Dr. Tony Szu-Hsien Lee. The whole manuscript was revised by my advisor Dr. Tony Szu-Hsien Lee and published in the journal of International Journal of Mental Health Nursing. 3. The Canonical correlation between CHI and PWB in Section 4.3 and Section 5 was from my analysis directed by my advisor Dr. Tony Szu-Hsien Lee and committee member Dr. Lin Lin. 4. The translation of the qualitative interview resulted in Section 4.8-4.11 was mostly discussed and revised with my classmate Chang-Hsun Chen. 5. The concept of analysis in Section 2.1 was developed by me during my visiting at the University Texas Health Science Center, Nursing School with the collaborating advisors and classmates in the Class of Nursing theory. In addition, this used ideas I had already developed in my own time.. Signature : Hui-Hsun Chiang. Date : Aug. 18. 2013. - ii -.

(4) Acknowledgements I would like to express my deep gratitude to Professor Tony Szu-Hsien Lee ( 李思賢) and Professor Lin Lin(林霖), my research supervisors, for their patient guidance, enthusiastic encouragement and useful critiques of this research work. I would also like to thank Dr. Li-Chan Lin (林麗嬋), Dr. Mei Chang (張媚) and Dr. Li-Kang Chi(季力康), for their advice and assistance in keeping my progress on schedule. My grateful thanks are also extended to Mr. Kao (高振楠) for his help in doing the process of administrative application, to Dr. Dav. V., who helped me promote the academic writing ability and presentation skills and to Ms. Mei-Yi Wu (吳美宜) for her support and encouragement in the school. Moreover, I would like to express gratitude to my colleague Xiao-Ping Lee(李小萍) for her support to share the work loading in the workplace. I would also like to extend my thanks to the partners Li-Hui Chien (簡鸝慧), Jie-Siang Lin (林頡翔), Yi-Hui Yeh (葉懿慧) of the laboratory of the department for their help in offering me the resources in collecting and analyzing the data of the program. I would like to express my very great appreciation to Mr. Chang-Hsun Chen (陳昶勳) for his valuable and constructive suggestions during the analyzing and development of this research work. His willingness to give his time so generously has been very much appreciated. Finally, I wish to thank my family, especially my two kids, for their support and encouragement throughout my study.. - iii -.

(5) Table of Contents 1 Introduction.........................................................................................1 1.1 Background and Context..................................................................................1 1.2 Purpose of study...............................................................................................2 1.3 Research hypotheses........................................................................................3 1.4 Significance of study........................................................................................4 1.5 Definition of terms...........................................................................................4 1.6 Theoretical perspective....................................................................................6 1.7 Limitation......................................................................................................11. 2 Review of literature..........................................................................13 2.1 Concept analysis of happiness........................................................................13 2.2 Influencing factors of happiness among perceived health, sense of coherence and family relationship ..........................................................................................22 2.3 Relationship among happiness, perceived health, sense of coherence and family relationship.................................................................................................25 2.4 Broaden and build effect of happiness on health...........................................30. 3 Methods.............................................................................................36 3.1 Research design..............................................................................................36 3.2 Conceptual framework...................................................................................46 3.3 Data collection procedure...............................................................................46 3.4 Data analysis..................................................................................................48 3.5 Ethical consideration......................................................................................52. 4 Results................................................................................................54 4.1 Sample characteristics of study 1...................................................................54 4.2 Reliability and validity of the PWB, family relationship and CHI scales......55 4.3 Dimensions of Chinese Happiness Inventory................................................58 4.4 Sample characteristics of study 2...................................................................59 4.5 Reliability testing of the CHI, family relationships and SOC scales for total number screened and enrolled in study 2...............................................................59 4.6 Influencing factors of happiness ...................................................................60 4.7 Path diagram of happiness on perceived health.............................................61 4.8 Result of qualitative interview in study 3.......................................................63 4.9 Motivation of change.....................................................................................64 4.10 Extend four resources...................................................................................66 4.11 Broaden and build effect..............................................................................74. 5 Discussion .........................................................................................87 6 Reference.........................................................................................106 7 Tables...............................................................................................134 8 Figures.............................................................................................150 - iv -.

(6) 9 Appendix 1. Instruments ...............................................................158 10 Appendix 2. Certificate of ethical consideration........................164 11 Appendix 3. Exercise prescription of walking exercise for retired elderly...................................................................................................165 12 Appendix 4: Teaching strategy and theory application of walking exercise ................................................................................................166 13 Appendix 5: Apply Teaching strategy and theory application of psychosocial intervention...................................................................168. -v-.

(7) List of Figures Figure 1.Concept model of happiness.......................................................................150 Figure 2.Conceptual framework...............................................................................151 Figure 3. Study Process.............................................................................................152 Figure 4: Final MIMIC model of psychological well-being and family relationships ...................................................................................................................................153 Figure 5: Helio plot of the first canonical variate.....................................................154 Figure 6: Helio plot of the second canonical variate................................................155 Figure 7: Full path model of the happiness , sense of coherence, family relationships and health ................................................................................................................156 Figure 8: Revised path model of the happiness , sense of coherence, family relationships and health .......................................................................................................157. - vi -.

(8) List of Tables Table 1. Definition of happiness...............................................................................134 Table 2. Sample characteristics of retired Taiwanese elders (N =268).....................136 Table 3. Sample characteristics of retired Taiwanese order people (N =248)..........137 Table 4. Summary of confirmatory factor analysis and reliability of the psychological well-being and family relationships scales using maximum likelihood estimation (N= 268)...........................................................................................................................138 Table 5. Model fit statistics for the results of MIMIC analysis...............................139 Table 6. Summary of Exploratory Factor Analysis Results for CHI scales Using principal axis factor (varimax rotation) (N = 248)..........................................................140 Table 7. Canonical corRelation analysis and prediction of CHI using PWB..........142 Table 8. Item-total correlation and Cronbach's α of CHI scales...............................143 Table 9. Sample characteristics of retired Taiwanese elders (N =142)....................144 Table 10. Item-total correlation and Cronbach's α of CHI scales............................145 Table 11. Item-total correlation and Cronbach's α of family relationships scales....146 Table 12. Item-total correlation and Cronbach's α of SOC scales............................147 Table 13. Pearson's correlation analysis....................................................................148 Table 14. R-square of perceived health, CHI and SOC............................................148 Table 15. Standardized effect from family relationship to CHI................................148 Table 16. Sample characteristics of retired elderly in qualitative interview(N =6). .149. - vii -.

(9) 1. Introduction. 1.1 Background and Context Aging is an global issue because of larger percentage of elderly populations . With the trend of life expectancy increasing, it was contributed to an aging population worldwide. Taiwan is currently challenged by a health burden for its elderly population. In 2010, 10.74% of its population was above 65 years old (Taiwan Directorate-General of Budget, Accounting and Statistics, 2011). With the aged population increasing, more and more medical resources were supplied for these population with higher morbidity and mortality. As people reach retirement, they experience a loss of physiological function, psychological and social involvement. Indeed, such losses are not necessary for everyone, however, in some cases such loss of function can leave persons physically and emotionally vulnerable. Aging brings with it a decline in one’s physical functions and accompanying with chronic disease, such as hypertension, diabetes, heart failure, coronary artery disease etc. Such changes may also cause a decline in the elderly person’s mental health status and well-being. Successful aging emphasize more on physical disability and cognitive function (Depp & Jeste, 2006; McGuire, Ford, & Ajani, 2006). However, it lacks emphasis of positive emotion such as happiness and well-being which also have big impacts on the issue of aging. A meta-analysis reported that positive well-being are associated with lower mortality and has a favorable effect on survival in both healthy and ill population (Chida & Steptoe, 2008). The scientific journal, Science, also advocated that the pursuit of happiness can have concrete benefits for well-being and -1-.

(10) indicated that happy people live longer (Frey, 2011). Issue of happiness are especially important for retired elderly both on physical health and mental health. Recently, the emphasis of positive emotion such as happiness become more and more popular and the broaden-and-build theory of positive emotion provided an evidence-based support for the functions of happiness. Current evidence supports that positive emotion undo the cardiovascular effects of negative emotions, and broaden the positive behavior to build the physical, intellectual, social and psychological resources (Fredrickson, Mancuso, Branigan, & Tugade, 2000). Research also indicated that, happiness is not only predicts for lower mortality, but may partly be mediated by more physical activity and lower morbidity (Koopmans, Geleijnse, Zitman, & Giltay, 2008). Nevertheless, despite happiness is an beneficial approach in the issue of health aging (Almeida, Norman, Hankey, Jamrozik, & Flicker, 2006; Cohn, Fredrickson, Brown, Mikels, & Conway, 2009). However, there is no practical evidence for retired elders to understanding the components of happiness and its influence factors. Besides, there is no empirical evidence to explain how people who become happier through the broaden and build effect. Therefore, this dissertation is an attempt to address the influence of happiness on health among retired elderly and fill the gap between happiness and physical health.. 1.2 Purpose of study The primary purpose of this study was to determine the components of Chinese Happiness Inventory and its influencing factors. Another purpose was to examine the relationships between happiness and physical, psychological and social factor. Finally, the aim is to detect the broaden and build process of happiness and its -2-.

(11) influence on health.. 1.3 Research hypotheses Research Hypothesis 1: 1-1. The validity and reliability of the Chinese happiness inventory is acceptable. Research Hypothesis 2: 2-1. Happiness status is positively related to perceived health. 2-2. Happiness status is positively related to sense of coherence. 2-3. Happiness status is positively related to family relationships. Research Hypothesis 3: 3-1. Happiness will mediate the positive relationships between family relationships and perceived health. 3-2. Happiness will mediate the positive relationships between sense of coherence and perceived health. 3-3. Sense of coherence will mediate the positive relationship between family relationships and happiness. Research Hypothesis 4: 4-1. The process of happiness promotion are consistent with the content of Broadenand-Build theory.. -3-.

(12) 1.4 Significance of study This study offers an non-trivial breakthrough on understanding the dimensions of Chinese Happiness Inventory and its influence on health. With the application of the Broaden-and-Build theory of positive emotion to understanding more on process of happiness promotion among retired elders at the theoretical and empirical level. Consequently, individuals who are happy exhibit many positive and long-lasting traits such as better coping, and then build better physiological state and be more healthier. Moreover, the result of this study provide additional knowledge about the gap from the conclusion of Science journal that happy people who live longer. Retired older adults with higher positive social connections will be more better on the family relationships and happiness status; people with more positive experience sharing will be more better on sense of coherence and happiness status. Thus, the contribution of the dissertation will provide an theoretical and empirical evidence of understanding the process of broaden-and-build to promote happiness and perceived health on retired adults, and then explain why happy people who live longer. Therefore, to attain successful aging will not only emphasize on disease control, physical health, but promoting positive emotion and mental health.. 1.5 Definition of terms Happiness Happiness is defined as “a mental state of satisfaction“, “a harmonious homeostasis of inner experience”, which has three major elements: positive affect, absence of negative affect and life satisfaction. The operational definition was measured by Chinese Happiness Inventory (CHI). The 20-item measurement was based -4-.

(13) on both Western questionnaire and qualitative research survey in Chinese population which has good criterion-related validity and consistency with the original version of CHI. Family relationship Family relationship is defined as “relatedness or connection by blood or marriage or adoption members or significant persons in daily life.” The operational definition of The Family Relationships measure in study 1 was constructed from a three-item scale: (1) “How much are your significant family members involved in your daily life?” (involvement), (2) “How are your emotional relationships with your close family members?” (emotional relation), and (3) “What is the atmosphere of your family interactions?” (sociability). Responses were made on a 4-point Likert scale: none or bad (1), sometimes or fair (2), often or good (3), and always or great (4). Possible scores ranged from 3 to 12, with a higher score indicating more positive family relationships. The Family Relationships measure in study 2 concluded threeitem scales with five more items about social/ family support of walking exercise for based on the purpose of psychosocial intervention. Responses were made on a 5-point Likert scale: none or bad (1), sometimes or fair (2), uncertain or as usual (3), often or good (4), and always or great (5). Possible scores ranged from 8 to 40, with a higher score indicating more positive family relationships. Sense of coherence Sense of coherence is defined by Antonovsky as the “ a global orientation that express the extent to which one has a pervasive, enduring though dynamic feeling of confidence that comprised of three components: (1) comprehensibility: a sense and. -5-.

(14) belief that you can understand and predict what things will be happen in your life and in the future; (2) manageability: a belief that you have the skills or ability to make things under your control; (3) meaningfulness: a belief that things in life are interesting and a source of satisfaction, that things are really worth it (Feldt et al., 2007). The operational definition was measured by 13-item Sense of Coherence (SOC) scale. The 13-item measurement has relatively high structural validity and high stability for the 13-item SOC measure especially for people over age 30 (Feldt et al., 2007). Perceived health status Perceived health status reflects people's overall perception of their health, including both physical, psychological and social dimensions. Perceived health status was assessed by asking, “How does your health affect your daily life?” Scores on this item ranged from 1 (often) to 4 (not at all).. 1.6 Theoretical perspective In formulation of theoretical perspective for promoting the elders' physical and mental health, the broaden-and-build theory of positive emotion provides a useful prototype. The conception of positive emotions posits the function to undo the cardiovascular effects of negative emotions (Fredrickson et al., 2000) and attempts to “broaden” an individual's momentary thought-action to be more creative, open minded, and then turns into “build” the resources ranging from intellectual and physical resources to social and psychological resources (Fredrickson, 2001). Basically, this middle range theory established a empirical foundation to interpret the connection of physical and mental health.. -6-.

(15) When it comes to the theory of broaden-and-build of positive emotions, it is necessary to describe the relation between the broaden-and-build theory and positive psychology first, the work of positive emotions were suggested by Barbara Fredrickson, a social psychologist who developed the broaden-and-build theory of positive emotions at the University of North Carolina, Chapel Hill, suggested that positive emotion lead to quickest recovery to the baseline of cardiovascular system (Fredrickson, 2003). Positive emotions is effective to broaden the broad-minded thinking and coping, contributing to psychological resilience by building psychological resources to enhance psychological well-being and emotional well-being (Fredrickson, 2001). The pursuit of happiness and psychological well-being are the purpose of positive psychology. Positive psychology is the science of human flourishing that proposed by Martin Seligman in 1998 (Froh, James, Maslow, Dewey, & Stanley, 2004),which has three central concerns: positive subjective experience (positive emotions), positive individual traits and positive instructions (Seligman & Csikszentmihalyi, 2000). First of all, positive subjective experience (positive emotions) are developed to engage into the contentment and satisfaction in the past; flow and happiness in the present; hope and optimism for the future (Seligman & Csikszentmihalyi, 2000). Moreover, positive individual traits are the capacity for love, vocation, perseverance, forgiveness, future mindedness, spirituality and wisdom, such as optimism, resilience, creativity, compassion and moderation (Seligman & Csikszentmihalyi, 2000). In the final, positive institutions are the strengths to use the positive traits that foster better subjective experience in social organizations, such as civility, altruism, citizenship, leadership (Robbins, 2008; Seligman & Csikszentmihalyi, 2000). Posi-. -7-.

(16) tive psychology, a science of satisfaction, purpose to flourish individual strength and virtue seeking for happiness, and overlap with humanistic psychology in thematic content and theoretical presupposition (Froh et al., 2004; Resnick, Warmoth, & Serlin, 2001; Robbins, 2008). Humanistic psychology is the third force of psychology, proposed by Abraham Maslow and Carl Roger. in 1950s, humanistic psychology was rooted in. existentialism and phenomenology, concerned with individual-centered and human being, and search for love, meaning, personal growth, psychological health, values, creativity, identity and happiness (Wertheimer, 1978). The core belief of humanistic psychology perspective have several concerns. Firstly, viewing the person as a whole and. believed that the whole is greater than the part (Buhler, 1971;. Wertheimer, 1978). In the nature of human, the focus always is on the value, will, belief and conscious thinking without assessment of person wholly on the basis of physics, chemistry and behavior. Because of individual experience , intention, being and belief, it can not be predicted and described completely of a whole human by describing partial characteristics. Second, focusing on human existence and phenomenological philosophy (Buhler, 1971; Rogers, 1963). Individual experience or existence of itself is an consciousness occurrence to phenomenon, focusing on what individual perceived is reality and emphasizing which is significant to himself and driving himself toward the destination. Finally, emphasizing on human values and motivation, in opposition to Freud's theory of psychoanalysis and believed that humans drive their behavior with their own motivations consciously(Buhler, 1971; Wertheimer, 1978). An individual with healthy human being may motive to have a goal of their own life, the most wildly-spread theory of Maslow's addressed that the end goal of life is self-actual-. -8-.

(17) ization, individual who realize the self-achievement as a growth precess in whole life (Buhler, 1971). Humanistic psychology means to flourish as a human being and eager for the pursuit of positive end of life.. It can not be deny that the assumption of the positive psychology and humanistic psychology, both emphasize on happiness, optimal experience and stress on self-centerlines, self-help movement, are consistent with the theory of broaden-andbuild of positive emotions (Cohn & Fredrickson, 2006; Robbins, 2008). The broaden-and-build theory of positive emotions was followed by the rule of positive psychology and humanistic psychology that intellectual core of the human potential movement can have a dramatically impact on the field of psychology (Fredrickson, 2001; Resnick et al., 2001; Schiffrin & Nelson, 2008) . Additionally, the undoing effect of broaden-and-build theory both are on reducing the physiological effect of stress and reducing the recovery time of cardiovascular activation (Cohn & Fredrickson, 2006; Fredrickson et al., 2000; Fredrickson & Levenson, 1998). When people with stress will suffer from physiological changes, including heart rate, blood sugar and blood pressure increased and immune-suppression, the changes will induced illness in the long run. However, positive emotion can reduce the effect of physiological changes and then decrease mortality and morbidity ( Fredrickson et al., 2000; Fredrickson & Levenson, 1998). Several study results are consistent with this hypothesis and showed that positive emotions can prevent the onset of suicide, depression, hypertension, diabetes, and respiratory tract infections and promote longevity (Frey, 2011; Hirsch, Duberstein, & Unützer, 2009; Richman et al., 2005). The function of broaden-and-build theory of positive emotions is to guide applications and implications to improve individual and collective function,. -9-.

(18) psychological well-being and physical health (Fredrickson, 1998). The theory applied in the filed of detecting the salivary progesterone in college students to discuss the relationships between stress, health and social contact (Brown et al., 2009), relationships of social support, positive affect, broad-ed mind coping, interpersonal trust and social support of undergraduates (Burns et al., 2008), exam the effect of positive emotions on mental health among community adults (Catalino & Fredrickson, 2011), applied the theory to build personal resources to predict long term behavior change (Cohn & Fredrickson, 2010), build the relationships of positive emotions, resilience and life satisfaction (Cohn et al., 2009), exam the hypothesis of building personal resources among working adults (Fredrickson, Cohn, Coffey, Pek, & Finkel, 2008), relationships between positive emotions and resilience after terrorist attacking (Fredrickson, Tugade, Waugh, & Larkin, 2003), developing intervention on schizophrenia patients (Johnson et al., 2011; Johnson, Waugh, & Fredrickson, 2010), relationships between resilience and positive emotions ( Tugade, Fredrickson, & Barrett, 2004; Tugade & Fredrickson, 2007; Tugade & Fredrickson, 2004) and relationships between cardiovascular response and emotions (Wager et al., 2009). The theory suggest that positive emotions have several functions as followings: (1) broaden one's attention and thinking; (2) undoing lingering negative emotional arousal; (3) fuel psychological resilience; (4) build consequential personal resources; (5) trigger upward spirals towards greater well-being in the future and (6) approaching human flourishing (Fredrickson, 2000). The broaden effect of positive emotions also shown that people experiencing positive affect show increased preference for variety and accept a broader attention to their tasks. Consequently, positive emotions function as an effective antidote for the negative influences of negative emotions along with the broaden effect. The undo effect of positive emotions suggest that people might improve their psychological well-being and also their physical health by cultivating experiences of positive emotions to cope with negative emotions. In other words, psychological resiliency will be promoted by increasing the coping. - 10 -.

(19) ability of negative situations. Psychological resilience is an enduring personal resource that augment people's enduring coping resources with the flexible and creative thinking. The concept support the idea of build effect posited by the broaden and build theory that positive emotions build personal resources to recovery psychological stress and predict more psychological well-being and growth. The relations between positive emotion and well-being are reciprocal, people with broadened thinking and positive meaning, which trigger the broadened attention and cognition and then build the personal resources and facilitate the coping with adversity. As this cycle continues, people build their psychological resilience and enhance their emotional well-being.. Undoubtedly, the broaden-and-build theory of positive emotions were applied to verify the relationships of each concept and hypothesis both with evidence-based data and social science validation, otherwise, the model also can guide the application of intervention. In our study, we applied the theory of positive emotions to develop the interventions of physical activity, psychological intervention using the intellectual resources, physical resources, psychological resources and social resources. Moreover, the theory purposed the positive emotions can promote the resilience of stress in mental health, decrease the physiological effect of stress. To interpret the relationships between happiness, physiological status and physical activity.. 1.7 Limitation It is noteworthy that we used a nonrandom, purposive sample that did not include persons who were severely ill or disabled. Thus, our findings cannot be generalized beyond this subpopulation. Extending our study to this broader population is an inviting possibility for future research.. - 11 -.

(20) Moreover, we investigated on happiness and perceived health has been crosssectional rather than longitudinal, cross sectional design which can not predict life expectancy. Therefore, it is necessary to survey longitudinal effect and life expectancy in the future. Finally, the process of happiness promotion was based on psychosocial intervention which designed for the implication of Broaden-and-Build theory which is suitable for Taiwanese retired elders, the process of happiness promotion may different from the variety of intervention, area, culture, country and society. Our process of happiness promotion can not be generalized beyond different intervention, population and different culture.. - 12 -.

(21) 2 Review of literature 2.1 Concept analysis of happiness Happiness is an important indicator of mental health and quality of life, especially for retired persons. Aging is viewed as a holistic social psychological phenomenon, and retirement is a significant developmental stage of life that brings with it major changes in a person’s roles and relationships, including status within the family, social status more broadly, and a loss of the sense of self-achievement that results from no longer working (Anson, Antonovsky, Sagy, & Adler, 1989). Aging brings with it a decline in one’s physical functions and changes in the family structure resulting, for example, from a spouse passing away or a son or daughter marrying. Such changes may also cause a decline in the elderly person’s mental health status and well-being. Therefore, the current analysis will refer to the concept of “happiness” in the retired aged population. The purpose of this article is to provide an analysis of the concept of happiness to develop a clear definition, identify attributes, antecedents and consequences of the concept, and develop model cases to form a clearly structured definition and contributed for further research and implication . 2.1.1 Definition of happiness The concept of '' happiness'' is a mental state of well-being characterized by positive psychology (Lu, 2001). Philosophers and religious thinkers often define happiness as having a good life, or flourishing, rather than simply as an emotion (Judge & Kammeyer-Mueller, 2011; Vitrano, 2010). There are tiny difference between East. - 13 -.

(22) and West countries because of culture difference (Lu et al., 2001). However, the concept of happiness is correspond to what positive psychology endeavor that getting in the flow of meaningful life (Majani, n.d.). It is certainly that the perspective from psychologist, scientist, economist, philosopher and religious thinker all suggested that the concept of happiness means a meaningful life and well-being. It seems that the concept of happiness is widespread whatever Eastern culture or Western culture. The study of happiness has been approached from a variety of perspectives. Though happiness is important in maintaining health, few studies of happiness can be found in the nursing literature. This paper analyzes the concept of happiness through examining its conceptual definition, defining attributes, antecedents, consequences, and conceptual model for clinical nursing implication to provide information and theoretical model for future research in the viewpoint of nursing. Happiness has been defined as below (Table 1). Happiness, understood as subjective well-being, both China and USA were characterized as a multidimensional construct that consists of cognitive and emotional elements (Davern, Cummins, & Stokes, 2007), and has three components: life satisfaction, positive affect and the absence of negative affect (Zhang, Yang, & Wang, 2009). It has been defined as “a mental state of satisfaction“, a harmonious homeostasis of inner experience especially in Chines culture(Lu, 2001). One of elements in happiness, life satisfaction, which means the individual's attitude to their own lives (Bekhet, Zauszniewski, & Nakhla, 2008), and consists of five factors: zest, resolution, congruence, self-concept, and mood tone (Bishop, Martin, & Poon, 2006). Happiness is originated form the “hedonistic “approach to well-being that generally defined as the presence of positive affect and the absence of negative affect (Deci &. - 14 -.

(23) Ryan, 2006). Core affect of happiness is the force behind individual to set point in homeostasis status (Davern et al., 2007). Happiness was probably composed of three related components, positive affect, absence of negative affect and life satisfaction, which was measured by Chinese Happiness Inventory (CHI). The 48-item measurement was based on both Western questionnaire and qualitative research survey in Chinese population and testing of reliability and validity in several studies (Lu & Lin, 1998; Lu & Shih, 1997; Lu, Shih, Lin, & Ju, 1997; Lu, 2006). The item total correlation are very high with no item dropped, exploratory factor analysis showed that only one factor with internal consistency was .95, test-retest reliability within 1 month interval was .66 (Lu & Shih, 1997). 2.1.2 Defining Attributes The function of critical attributes are much like criteria for making differential diagnosis and help to differentiate the concepts from others similar or related to it (Walker & Avant, 2011). According to Lee and Im (2007), the meaning of self-enhancement refers to people’s conscious or unconscious distortion,ignorance or omission of incoming stimuli so that they can perceive themselves in more positive, favorable manner. Therefore, Elderly people with higher self-enhancement were predicted to perceive negative life events less negatively and perceive more positive life events. A correlation of 0.26 was found between subjective happiness and self-enhancement (Lee & Im, 2007). On the other hand, elderly with more self-enhancement is believed to help coping in stressful situations, and help engagement in productive and creative work (Lee & Im, 2007), so self-enhancement can contributed to the ability of stress coping ability in positive way. - 15 -.

(24) Sense of coherence( SOC) is described as a part of the individual’s way of coping with life, not as a personality variable (Söderberg, Lundman, & Norberg, 1997). There are three mutually interacting components: comprehensibility, manageability and meaningfulness (Shiu, 2004). Sense of coherence was defined as “ a global orientation that expresses the extent to which one has a pervasive, enduring, thought dynamic, feeling of confidence that one's internal and external environment are predictable (Antonovsky & Sagy, 1986). Study results indicated that SOC is a good predictor of the individual retiree's adaptation and also plays an important role in coping with stressful experiences of individual who experienced a major life transition of retirement (Sagy & Antonovsky, 1992). Moreover, SOC contributes to mental health and psychosocial functioning and also contributes to emotional well-being in the face of constant tension arising from managing chronic illnesses (Shiu, 2004). SOC is related to perceived level of stress and well-being, also related to life satisfaction (Söderberg, Lundman, & Norberg, 1997). As noted previously, life satisfaction is the core element of the happiness,which means satisfied with life as a whole accompanying with presence of positive affect and absence of negative affect. However, satisfaction of a whole life can be originated from a higher SOC because of the ability of stress coping and also contributed to enhance the level of self-enhancement that they can perceive themselves in more positive way. 2.1.3 Variables associated with happiness Many studies have examined the associations between happiness and a number of variables. Economists proposed that social economical status such as income, education level were found to have indirect effects on happiness (Bishop et al., - 16 -.

(25) 2006). Otherwise, culture diversity is another important variable associated with happiness. The Chinese culture are originated most from Confucian values, which emphasized the harmony of the group and stress the collective welfare of the family (Lu, 2001). The traditional (social- oriented) Chinese self differs from the Western culture (individual-oriented), and then under this collective orientation, Chinese culture emphasizes positive relations with others and stresses the happiness as a harmonious homeostasis (Lu, 2008). Studies also showed that the quality of governance and welfare policy appears to be more important for happiness (Ott, 2009). 2.1.4 Antecedents Many predictors of happiness have been identified in the literature. Most of the studies, however, were conducted with predicting happiness found that physical factor, psychological factors and social factors can indirectly improve subjective well-being. Antecedents affecting the concept of happiness in physical elements include physical activity and healthy life style (Knechtle, 1999; Piqueras, Kuhne, VeraVillarroel, van Straten, & Cuijpers, 2011), exercise, health status (Rasciute & Downward, 2010), medical problems (Hirsch et al., 2009). Moreover, the psychological factors include cognitive performance, psychological variables (Kim, 2003), such as emotion, mood, depression and perceived stress (Schiffrin & Nelson, 2008), self-efficacy and optimism (Bowling & Iliffe, 2011). Finally, the social factors include social support (Ngai & Chan, 2011; Warburton, Bartlett, & Rao, 2009), family support (Warburton et al., 2009), and friendship (Demir & Özdemir, 2009; Demır & Weitekamp, 2006). For the purpose of this analysis, the antecedents to the production of the happiness in retired elders have been broadly classified as physical, psychological and social factors, because any factor of physical impairment, psychological - 17 -.

(26) distress or social isolation can depress the level of happiness and vice versa. 2.1.5 Consequences Studies have examined the consequences of happiness mostly focused on successful aging in aged population. Successful aging as avoiding disease by taking preventive measures, minimizing risks for disability, having good cognitive and physical function and engaging in life (Hsu, Tsai, Chang, & Luh, 2010). Successful aging was defined as follows: the living environment in a community or city is beneficial for physical, psychological and social health, and the people living in the area are well informed about the issues that pertain to maintaining health and behave in ways that promote their health (Hsu, et al., 2010). There are two main components: physical health and mental health. Several studies show that happiness can prevent the onset of depression, hypertension, diabetes, and respiratory tract infections (Richman et al., 2005; Wood & Joseph, 2010), and a meta-analysis confirms that happiness is a protective factor for survival in both healthy and diseased populations (Chida & Steptoe, 2008). On the other hand, studies also showed that happiness was inversely associated with mortality, which predicts for lower mortality and longer life expectancy, which may partly be mediated by more physical activity and lower morbidity (Frey, 2011; Koopmans et al., 2008). Moreover, happiness also benefit to mental health. A10 years longitudinal study indicated that the absence of positive well-being forms a substantial risk factor for depression, in other word, when people have more happiness can prevent them form depressed (Wood & Joseph, 2010). A cohort study also revealed that decreased risk thoughts of suicide is predicted by the presence of happiness (Hirsch et al., 2009). Thus, preventing from depression and suicide could be a consequence of happiness. However, a cross-sectional study that - 18 -.

(27) examined self-reported happiness is strongly related to mental health status (Perneger, Hudelson, & Bovier, 2004). However, the concepts of quality of life and happiness relate to each other remains a matter of debate. Happiness is another and more prominent aspect of the quality of life (Ventegodt, Andersen, & Merrick, 2003). Happiness and subjective well-being are mutually interrelated, and indeed they are all closely connected with the notion of quality of life (Susniene & Jurkauskas, 2009). Enhancement of happiness is considered a form of alternative medicine, because it promotes good mental health by increasing brain opioids, such endorphen (Ryff & Singer, 1998). Thus, mental health could be a consequence of happiness. The happiness model includes antecedents, attributes and consequences as Figure 1. 2.1.6 Influencing factors of happiness. 2.1.6.1 Intellectual factors: Intellectual resources provide individual with the means of buffering the effect of chronic disease and illness with effective compensation (Caplan & Schooler, 2003). Older people, frequently with age-related cognitive decline, need compensation for problem solving skills by cognitive or intellectual resources to create appropriate environmental accommodation or improve personal capacity (Caplan & Schooler, 2003). Emotion appraisal are different from individual's intellectual or cognitive mechanism (Forgas, 2008). Happiness are interpreted through appraisallike processes, and the procedure are influenced by intellectual or cognitive resources. On the other hand, persons with positive affective state may selectively recruit assimilative and adaptive cognitive strategies to operate tasks (Forgas, 2008). Positive perception and the source of happiness are positively associated with re-. - 19 -.

(28) framing coping strategies through intellectual or cognitive appraisal, the firmly characteristic and concept were identified by the study of mothers with disability children (Hastings, Allen, McDermott, & Still, 2002), Happiness emerges from available data as the resource leading to the development and better use of intellectual skills and resources (Kesebir & Diener, 2008). 2.1.6.2 Physical factors: Health status is an significant factor of physical resources to predict the status of happiness. Study indicated that the happiness perception of institutional caregiver were predicted by perceived health status (Lin, Lin, & Wu, 2010). Health is likely to be a important determent of happiness that happiness increase with health status (Gerdtham & Johannesson, 2001). A study based on 6,576 Norwegain twins to examine the relations between happiness and health status and result showed that happiness correlated .50 with health status (Røysamb, Tambs, Reichborn-Kjennerud, Neale, & Harris, 2003). Moreover, a survey of life circle happiness in U.S. revealed that happiness edges downward as a continuing decline with a satisfaction with health status (Easterlin, 2006). A survey indicated that happiness was directly influenced by reported perception of health among older black Americans (Chatters, 1988). Above all, it can not be deny that health status plays an important role in happiness. Health status may protect against negative affect perception, and vice versa (Steptoe, Wardle, & Marmot, 2005). Happiness and health status are highly intercorrelated and reciprocal elements.. - 20 -.

(29) 2.1.6.3 Psychological factors: The cause of happiness are highly correlated with psychological factor, such as self-esteem, emotion, self-efficacy. A study focused on 234 participants who mean age are 18.23 years exploring the predictors of happiness and result showed that self-esteem had a direct predict power .49 on happiness (Cheng & Furnham, 2003). Another study exploring associations between happiness and psychosocial factors among adolescents showed that self-efficacy increased the odds of happiness (Natvig, Albrektsen, & Qvarnstrøm, 2003). However, psychological factors are correlated with intellectual factors, such as coping, appraisal, with physical factor of health status, and these factors explains a significant correlation with psychological symptom (Folkman, Lazarus, Gruen, & DeLongis, 1986). Psychological status is a complicated outcome of intellectual, physical, psychosocial resources. Improving psychological factors of self-esteem or self-efficacy, emotion focused not only psychological domain, but intellectual, physical, social domains. 2.1.6.4 Social factors: Social support is an important element in the domain of social factor, which help to reduce the deleterious effect of stress and promote happiness indirectly through self-esteem (Krause, 1987a). Social support counterbalances or buffers the negative effects of life stress among older adults and prevent them form depression (Krause, 1987b). Social support significantly correlated with emotional well-being (Abbey, Abramis, & Caplan, 1985).Improvement in social relations helped to buffer the decline in satisfaction of life and helped to offer a supportive exercise environment for older adults to improve their happiness (McAuley et al., 2000). Moreover, social support from family members or friends also helpful to buffer the decline of - 21 -.

(30) happiness. Family life is slightly positive correlated with happiness (Easterlin, 2006). Studies showed that relationship with parents had a direct predictive power .18 of happiness (Cheng & Furnham, 2003). Friendship was also a significant predictor of happiness(Cheng & Furnham, 2002; Csikszentmihalyi, 2003). It seems that social relations to the supportive environment are significant determinants of happiness.. 2.2 Influencing factors of happiness among perceived health, sense of coherence and family relationship In the following, we will discuss the influencing factors of happiness in physical, psychological and social components with evidence-based literature. 2.2.1 Influence factors of perceived health Happiness are highly correlated wit health status and may influence health status (Chatters, 1988; Edwards & Cooper, 1988; Gerdtham & Johannesson, 2001; Røysamb, Tambs, Reichborn-kjennerud, Neale, & Harris, 2003). A meta-analysis indicated that general life stress, anxiety, neuroticism, or negative affect were associated with poor cardiovascular (heart rate or blood pressure) recovery (Chida & Hamer, 2008). Happiness has direct or indirect influences on health by undoing the negative cardiovascular effect (Fredrickson et al., 2000) and affect health behavior (Argyle, 1997a). Moreover, happier people report systematically lower level of hypertension (Blanchflower & Oswald, 2008). Positive affect contributes to the extent of changes in basal level of cardiovascular activity. In addiction, positive affect may not related to myocardial ischemia but negative affect was associated with it (Pressman & Cohen, 2005).. - 22 -.

(31) Happiness and perceived health are reciprocal and mutually correlated. Happiness was highly positively associated with perceived health and influenced by genetic factors based on 6576 Norwegian twins survey (Røysamb, Tambs, Reichborn-kjennerud, et al., 2003). Happiness may have positive impact on health through against ill-health and risk of disease (Argyle, 1997; Steptoe & Wardle, 2005). Also, happiness is associated with increased longevity and lower morbidity, especially in the older individual (Pressman & Cohen, 2005). In other words, negative affect produce more illness, for example, the presence of psychological distress may increase the risk of cardiovascular disease through healthy behavior change (Hamer, Molloy, & Stamatakis, 2008). On the other hand, happiness was directly influenced by health satisfaction (Chatters, 1988). Happiness and perceived health are inter-correlated. 2.2.2 Influencing factors of sense of coherence (SOC) SOC is an indicator of psychological factor, such as quality of life, less depression, mental health, purpose in life and contentment (Neuner et al., 2011; Delgado, 2007; Eriksson & Lindström, 2007; Nygren et al., 2005).Strong association between SOC and psychological status were verified as following studies. SOC is a predictors/ indicator of health-related quality of life (Julkunen & Ahlström, 2006; Khanjari, Oskouie, & Langius-Eklöf, 2012).Besides, a larger Finnish survey applied on aged people (over 75 years) indicated that SOC is positive correlated to happiness (r=.19, p<.001) (Elovainio & Kivimäki, 2000). Moreover, a system review indicated that SOC is strongly related to mental health(Eriksson & Lindström, 2006). SOC is positively related to quality of life, contentment and negatively related to anxiety and stress (Antonovsky & Sagy, 1986; Everson, Darling, & Herzog, 2013; Eriksson & Lindström, 2007; Everson et al., 2013; Schiffrin & Nelson, 2008; - 23 -.

(32) Schiffrin & Nelson, 2008). For example, study investigated the association between SOC and depression, 50 patients diagnosed with major depressive disorder and to 50 control subjects were administered and the result showed that significant negative correlation was found between total scores of SOC and depression (r=-.32, p<.05) (Carstens & Spangenberg, 1997). However, only a few study using emotional sense of coherence scales showed that SOC was significantly associated with physical health (r = 0.266; p < 0.05), while it was not significantly associated with psychological health (r = 0.006; NS). (Flensborg-Madsen, Ventegodt, & Merrick, 2006). After constructing a new scale of SOC, the result indicated that SOC are better associated with physical health (r = 0.362) and also associated with psychological health (r = 0.259; p < 0.01). (Flensborg-Madsen et al., 2006). 2.2.3 Influence factors of family relationships Several studies has shown a connection between family relationship or social support and happiness (Elovainio & Kivimäki, 2000). In all 234 participants (mean age=18.23 years) study in UK reported the association between personality, self-esteem, positive affect, depression and happiness. From the result, the path model indicated that self-esteem and relationship with parents had a direct predictive power on happiness (r=0.49, P<0.001; r=0.18, P<0.05) and the opposite relationship with depression, otherwise, happiness are positively correlated with family relationships (r=.41) and friends relationships (r=.38) (Cheng & Furnham, 2003). Another study investigated the association between social support and happiness in adolescents also indicated that social support from teachers also enhanced happiness significantly among 887 Norwegian school adolescents (Natvig et al., 2003). - 24 -.

(33) Successful aging emphasized the enhancement of family relationships and friendship, people who depend on these relationships for instrumental, emotional and financial support and resulted in socially and psychologically well-adjusted (Adams & Blieszner, 1995). For retired elderly, social network and social support outside the place of work can buffer the negative health effects of job strain after etirement (Falk, Hanson, Isacsson, & Ostergren, 1992). Social relationships and family relationship are significant not only for happiness, physical health but mortality. For older people, social relations integrate to the exercise environment are significant determinants of happiness (McAuley et al., 2000). In the field of perceived health and mortality, social relations play an important role influenced between self-rated health and mortality in a representative sample of 6693 adult Danes. In addition, weaker structural social relations increased mortality directly (Helweg-Larsen, 2003). However, the relations among social resource, health, stress and happiness were examined among a national sample of 581 US. Black adults aged 55 years and over, results indicated that happiness was directly influenced by stress and reported satisfaction with health and stress, although social resource had a limited impact on happiness ratings but it was important in predicting intermediate factors related to health status and stress (Chatters, 1988).. 2.3 Relationship among happiness, perceived health, sense of coherence and family relationship In the following, we will discuss the relationship between the pair of the sense of coherence, perceived health, family relationships and happiness with evidence-based literature. - 25 -.

(34) 2.3.1 Family relationship and sense of coherence The cause-effect relationships between family relationships and sense of coherence were unknown. Study result showed that family relationships and sense of coherence are inter-correlated with significantly positive relation(r=.17), otherwise, both sense of coherence and social support were related negatively to morbidity and positively to both perceived state of health and subjective well-being(Elovainio & Kivimäki, 2000).Another study with personal interview survey collected in 1994 (N=8650, response rate 73%) with ages 25–64 (N=6506, 49% women), result of the study revealed that the factors contributing to sense of coherence included the quality of the relationship with partner, family and social relationships, social support (Volanen, Lahelma, Silventoinen, & Suominen, 2004). Family relationships may have significant influence on sense of coherence. The study investigated relationship about stress, cope with stress and relationships influences one’s sense of coherence (SOC) which incorporating 596 college students indicated that family relationships had the greatest effect on SOC for males, whereas emotional health had the greatest effect on SOC for females (Darling, McWey, Howard, & Olmstead, 2007).. 2.3.2 Family relationships and happiness Family relationships bring out highly social support is positively related to happiness (Elovainio & Kivimäki, 2000). The result of the analysis between social or family support and psychological well-being applied on 183 college students showed that domain support had a significant unique association with measures of well-being (Davis, Morris, & Kraus, 1998). The study explored the psychological and social re-. - 26 -.

(35) sources of aged people (over 75 years) in Finland and predict their subjective wellbeing and experienced state of health (n = 348). The result revealed that high experienced quality of social relationships, such as family relationships or social relation are strongly related to subjective well-being (r=.27, p<.001) (Elovainio & Kivimäki, 2000). A study investigated the correlations and causes of happiness and depression among 234 participants (mean age=18.23 years) adolescents, the path model showed that family relationships had a direct predict power on happiness (ß=0.18, P<0.05) (Cheng & Furnham, 2003). Another study examined the factors predicting happiness among ninety adolescents ranged in age from 16 to 18 and the mean age was 17.23 (S.D.=0.65) in the U.K. And indicated that friendship (b=0.23, t=2.07, p<0.05) was significant predictors of happiness (Cheng & Furnham, 2002). Above all studies, family relationships and social relationships may beneficial for happiness are proposed.. 2.3.3 Sense of coherence and happiness The role of sense of coherence (SOC) in psychological functioning are still unclear. A study obtained a sample of 193 adults (30–85 years old) indicated that SOC mediating the relationships between psychological experience, such as anxiety, stress, worry, and psychological well-being; SOC was negatively related to stressful experiences and positively related to psychological well-being (Gana, 2001). Another study applied on the population of breast cancer survivors also indicated that SOC was positively associated with psychological well-being, SOC was significantly positively related to psychological well-being (r= .594, P<.01)(Gibson & Parker, 2003).. - 27 -.

(36) Sense of coherence (SOC) is a disposition that seeing the world as comprehensible, manageable, and meaningful, seems linked to greater stress-resistance and better health (Amirkhan & Greaves, 2003). A community-based, longitudinal field study (n=75) verified associations among coherence, coping, and health. Moreover, they yielded a causal model which showed the disposition to both directly impact health status, and to operate indirectly via coping, which related to mental health via psychological coping and resiliency (Amirkhan & Greaves, 2003). SOC seems to have a mediating or moderator role to predict health (Amirkhan & Greaves, 2003). A study focused on age people from Finland also indicated that sense of coherence is a predictor of happiness; a strong sense of coherence and high experienced quality of social relationships are strongly related to happiness (Elovainio & Kivimäki, 2000).. 2.3.4 Happiness and perceived health There is quite a lot of evidence that happiness can influence health directly (Argyle, 1997b; Engström, Henningsohn, Steineck, & Leppert, 2005; Ryff, Singer, & Dienberg Love, 2004). An empirical study indicated that psychosocial factors contribute significantly to the pathogenesis and expression of coronary artery disease (CAD), result also revealed that chronic psychosocial stress can increase the risk of coronary artery atherosclerosis as well as to transient endothelial dysfunction and even necrosis through excessive sympathetic nervous system activation (Rozanski, Blumenthal, & Kaplan, 1999). Acute stress triggers myocardial ischemia, enlarges arrhythmogenesis, stimulates platelet function, and increases blood viscosity through hemoconcentration, acute stress also causes coronary vasoconstriction. Otherwise,. - 28 -.

(37) hyperresponsivity of the sympathetic nervous system, manifested by exaggerated heart rate and blood pressure responses to psychological stimuli, is an intrinsic characteristic among some individuals (Rozanski et al., 1999). Another study also indicated that cardiovascular health is more consistently associated with optimism and happiness. Moreover, positive well-being is also positively associated with restorative health behaviors(e.g., smoking, alcohol consumption, physical activity, sleep quality and quantity, and food consumption) and biological function(e.g., cardiovascular, inflammatory, and metabolic processes) that are most relevant for cardiovascular health (Boehm & Kubzansky, 2012). The pursuit of happiness can have concrete benefits for health and longevity (Danner, Snowdon, & Friesen, 2001; Frey, 2011). A system review indicated that positive affect could contributed to physical health, and suggested that an association of positive affect with lower morbidity, decreased symptoms and pain, increased longevity among older community-dwelling individuals and surviving serious illness (Pressman & Cohen, 2005). A meta-analysis synthesized 17 studies on emotional well-being as predictor of the prognosis of physical illness, the findings show that emotional well-being predicts long-term prognosis of physical illness (Lamers, Bolier, Westerhof, Smit, & Bohlmeijer, 2012).Also, study combined with 30 follow-up studies on happiness and longevity revealed that happiness does predict longevity among healthy populations, therefore, happiness does not cure illness but it does protect against becoming ill (Veenhoven, 2007).. - 29 -.

(38) 2.4 Broaden and build effect of happiness on health. 2.4.1 Broaden effect on personal resources. 2.4.1.1 Intellectual resources: Intellectual resources provide individual with effective compensation to appraise the happen of life events, which consist of positive experience sharing and personal counseling. Greater intellectual resources, a combination of intellectual flexibility and education, predict less degree of illness and less gross motor difficulty in older adults (Caplan & Schooler, 2003). Intellectual resources is beneficial for solving problem skill and manageability of life events by improving the level of selfefficacy. 2.4.1.2 Physical resources: Physical factors, such as health status, health behavior etc., are highly associated with health status and physical activity. Studies focused on twins of 2311 boys , 2717 girls to investigated the association with physical activity, health behavior and health status. Result showed that physical inactivity are associated with a less healthy lifestyle and poor perceived health status (Aarnio, Winter, Kujala, & Kaprio, 2002). More physical activity are based on health status, psychosocial versus demographic variables (Boslaugh, Kreuter, Nicholson, & Naleid, 2005). Another study investigated the association of health status, physical activity and well-being of fertility-aged women, the result showed that physical active women have better general health status and experienced better mental health (Kull, 2002). Also, study showed that the influencing factor of physical activity including the general health. - 30 -.

(39) status for women, positively relations between physical activity and general health status (MacDougall, Cooke, Owen, Willson, & Bauman, 1997). 2.4.1.3 Psychological resources: Psychological factors, such as self-efficacy, life satisfaction, quality of life and sense of coherence, are associated with happiness. Sense of coherence was significantly and strongly related to perceived health and is important to predict the psychological status (Eriksson, Lindström, & Lilja, 2007). Cross-sectional survey of 1257 randomly selected university students in Switzerland revealed that feeling happy all or most of the time was strongly associated with better mental health but also with the feeling of getting enough love and affection, and higher self- esteem (Perneger et al., 2004). Several studies indicated that interventions combined with physical activity and psychological resources could significantly promote psychological status and also beneficial to health status (Penedo & Dahn, 2005). Another study result using structural equation model to examine 249 older adults the roles played by physical activity, health status and self-efficacy in quality of life. Result indicated that the relations of physical activity and self-efficacy, physical activity and quality of life are indirect. However, physical activity activity influences self-efficacy and quality of life through mental health and physical health (McAuley et al., 2006). Another result indicated that physical activity was significantly correlated with self-efficacy and physical self-concept in preadolescences (Annesi, 2006). In conclusion, psychological factors, such as self-efficacy, sense of coherence, was directly or indirectly associated with happiness and be an indicator of psychological resources. - 31 -.

(40) 2.4.1.4 Social resources: Social factors associated with positive social connection, social support and family relationships in older population are important to facilitate increasing physical activity, facilitating functional capacity, preventing disease and promoting successful aging (Booth, Owen, Bauman, Clavisi, & Leslie, 2000). Social relationships, social support and family relationships would have direct and indirect (through depressive symptoms) effects on health behaviors and then beneficial for health status (Franks, Campbell, & Shields, 1992). The study results support the primacy of family functioning factors in understanding the associations among social relationships, mental health, and health behaviors (Franks et al., 1992). Factors associated with psychosocial resources were social support and family contexts. A ten year literature indicated that psychosocial factors such as depression and low social support are established risk factors for poor prognosis in patients with heart disease (Compare et al., 2013). To sum up, social factors including social support, family relations, friendships, environmental facilitations could influenced in happiness.. 2.4.2 Build effect on happiness and health The mechanisms underlying the association between happiness and health remain a mystery. We hypothesize that an upward spiral dynamic continually reinforces the tie between happiness and health status, mediated by people’s perceptions of their positive social connections. Studies suggested that positive emotion undo the cardiovascular effects of negative emotions, positive emotion such as joy, interest, love and contentment (Fredrickson, Mancuso, Branigan, & Tugade, 2000).. - 32 -.

(41) Compared to people in the other conditions, participants who experience positive emotions show heightened level of creativity, inventiveness (Fredrickson, 2003). Moreover, positive emotions promote discovery of novel and creative actions, ideas and social bonds, that broaden an individual’s momentary thought, otherwise, through the discovery of novel ,creative actions, ideas and social bonds, which in turn to build the individual’s personal resources (Fredrickson, 2004). Positive emotions broaden people's momentary and playful behavior. These broadened thought-action behaviors enabled to build intellectual, physical, social, psychological resources for the future (Fredrickson, 2003). These resources are beneficial to positive psychology and correlated with happiness and health status. Positive emotions, such as joy, happiness, trigger individuals to develop personal resources (Fredrickson, 2000). Before addressing the broaden effect of personal resources, recognizing the motivation of changes in the process of behavior change is significant. Cues to action seems to play an initial role in the process of behavior change, which means an external influences promoting the desired behavior, may including social influence, reminders by significant others, personal experience and persuasive communications (Meillier, Lund, & Kok, 1997). Cues to action is not only an external influencing factor, but a spiritual vigor especially given from significant persons. Moreover, positive circumstance changes and positive activity changes comes after behavior change also make it efficient to pursuit happiness (Lyubomirsky, Sheldon, & Schkade, 2005). People who experience warm, positive emotions live longer and healthier. Indeed, prospective evidence connecting happiness or positive emotions to physical health and longevity has steadily grown. Several studies show that positive emotion. - 33 -.

(42) can prevent the onset of depression, hypertension, diabetes, and respiratory tract infections (Richman, Kubzansky, Maselko, Kawachi, Choo, & Bauer, 2005; Wood & Joseph, 2010), and a meta-analysis confirms that positive emotion is a protective factor for survival in both healthy and diseased populations (Chida & Steptoe, 2008). Experiencing frequent happiness, for instance, associated with social connectedness, emotional and practical support and adaptive coping response (Steptoe, O’Donnell, Marmot, & Wardle, 2008), engendered success (Lyubomirsky, King, & Diener, 2005), contributed to physical health and longevity (Diener & Chan, 2011), forecasts having fewer colds (Cohen, Alper, Doyle, Treanor, & Turner, 2006) and reduced neuroendocrine, inflammatory, and cardiovascular activity (Steptoe et al., 2005). Complementing this prospective literature, a meta- analysis collected 150 experimental, longitudinal studies to test the impact of happiness on objective health outcomes found that the impact of happiness on improving health was stronger for immune system response and pain tolerance, but happiness was not significantly related to increases in cardiovascular and physiological reactivity (Howell, Kern, & Lyubomirsky, 2007). Another study indicated that positive emotion is positively associated with cardiovascular health, and robustly associated with health behavior or reduced risk event (Boehm & Kubzansky, 2012). The results leave little doubt that positive emotion in general predicts longevity. In some studies happiness was associated with cardiovascular health only efficient in health behavior and biological function, such as only in physical activity, smoking consumption, cardiovascular and inflammatory process, and such differences provide leads for future research.. - 34 -.

(43) The broaden effect of positive emotion emphasize that positive emotion broaden the scope of attention and cognition (Fredrickson & Branigan, 2005) and broaden individuals' habitual modes of thinking and build their personal resources for coping (Fredrickson, 2000). Otherwise, based on the broaden mindset and thinking, which, in turn, produced increases in a wide range of personal resources (e.g., increased social support, purpose in life, decreased illness symptoms ( Fredrickson, Cohn, Coffey, Pek, & Finkel, 2008). Therefore, the aim of this study is to investigate the impact of happiness broaden open mindset and build their personal resources, and then promote health outcome by reinforces the connection between happiness and physical activity, and detect whether the process mediated by people’s perceptions of their positive social connections.. - 35 -.

(44) 3 Methods. 3.1 Research design The quantitative data analyzed in this dissertation and participants of qualitative interviews were a part of a Dr. Tony Szu-Hsien Lee’s project entitled ‘Gender differences and influence of walking exercise and a psychosocial intervention on psychological well-being and sense of coherence amongst retired senior citizens’. The project was funded by National Science Council, ROC. (Grant No. 99-2410-H-003-127-MY2) and aim to investigate the effect of walking exercise and psychosocial intervention on physical activity, sense of coherence and happiness among retired elderly and its gender difference. It is a two-year true-experimental study. Constructing a reliable and valid instrument in the first year; and then discuss the influence of 3-month psychosocial and group walking intervention in the second year which applied on three group: (1) psychosocial intervention and group walking; (2) group walking and (3) individual walking. The process and result of this project could be refer to the project report of National Science Council of Dr. Tony SzuHsien Lee. Combining qualitative and quantitative research methods were used in this dissertation. First step was to use quantitative approaches to examine the construct of happiness. A face-to-face interview based on a structured questionnaire to investigate the dimensions of Chinese Happiness Inventory and examine the relationship between happiness and related factors. Three steps were used to investigate the concept of happiness. First, a pilot was conducted to detect the dimensions of the Chinese. - 36 -.

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