Using a Gratitude Intervention to Enhance Well-Being in Older Adults

Abstract

The increasingly ageing population includes a proportion of well older adults that may benefit from low-level psychological support to help maintain their wellbeing. A factor consistently regarded as integral to wellbeing is gratitude. The effect of a ‘Three good things in life’ gratitude intervention on hedonic and eudemonic wellbeing and perceived stress levels in non-clinically depressed older adults was examined. This intervention has not been evaluated with older adults previously. The duration of the intervention was 2 weeks and baseline, end of intervention and 30-day follow up measures were compared. The effects of online and paper delivery of the intervention were compared and differences in acceptability of the two routes examined. The daily positive events identified by participants were also analysed. Participants were 88 healthy community living adults aged 60 years or over. The intervention produced significant differences in eudemonic wellbeing as measured by flourishing from baseline to day 15 that was maintained at day 45. Significant increases in flourishing were evident from baseline to day 45. There were decreases in perceived stress from day 1 to day 15 but these were not maintained once the intervention ended. There were no significant differences between online and paper delivery of the intervention. This age group managed and many preferred online delivery, Gratitude diaries seem to be a cost-effective method of producing beneficial improvements in wellbeing for older adults.

Full text

RESEARCH PAPER
Using a Gratitude Intervention to Enhance Well-Being
in Older Adults
Alison Killen •Ann Macaskill
Published online: 20 June 2014
ÓSpringer Science+Business Media Dordrecht 2014
Abstract The increasingly ageing population includes a proportion of well older adults
that may benefit from low-level psychological support to help maintain their wellbeing. A
factor consistently regarded as integral to wellbeing is gratitude. The effect of a ‘Three
good things in life’ gratitude intervention on hedonic and eudemonic wellbeing and per-
ceived stress levels in non-clinically depressed older adults was examined. This inter-
vention has not been evaluated with older adults previously. The duration of the
intervention was 2 weeks and baseline, end of intervention and 30-day follow up measures
were compared. The effects of online and paper delivery of the intervention were com-
pared and differences in acceptability of the two routes examined. The daily positive
events identified by participants were also analysed. Participants were 88 healthy com-
munity living adults aged 60 years or over. The intervention produced significant differ-
ences in eudemonic wellbeing as measured by flourishing from baseline to day 15 that was
maintained at day 45. Significant increases in flourishing were evident from baseline to day
45. There were decreases in perceived stress from day 1 to day 15 but these were not
maintained once the intervention ended. There were no significant differences between
online and paper delivery of the intervention. This age group managed and many preferred
online delivery, Gratitude diaries seem to be a cost-effective method of producing bene-
ficial improvements in wellbeing for older adults.
Keywords Older adults Gratitude Online delivery Wellbeing Three good things
intervention
A. Killen A. Macaskill
Development and Society, Sheffield Hallam University, Room U0803, Unit 8 Science Park,
Sheffield S1 2 WB, UK
e-mail: a.macaskill@shu.ac.uk
A. Killen (&)
Institute for Ageing and Health, Newcastle University Campus for Ageing and Vitality,
Newcastle Upon Tyne NE4 5PL, UK
e-mail: alison.killen@ncl.ac.uk
123
J Happiness Stud (2015) 16:947–964
DOI 10.1007/s10902-014-9542-3

1 Introduction
Ageing is often viewed from a deficit-oriented and pessimistic perspective that focuses on
losses in areas such as health, independence, and memory. However, ageing can take many
courses. It can be characterized by risks and losses, but also by the presence of extensive
strengths that enable maintenance of positive wellbeing despite losses. The well elderly
constitute an important group to target with low-level maintenance support particularly due
to the increasing proportion of older adults within the population. The Expectations
Regarding Aging Survey (Sarkisian et al. 2002) found more than 50 % of participants felt
becoming depressed was an expected part of aging. Depression is a severe health problem
and one of the most prevalent conditions in later life, (Van’t Veer-Tazelaar et al. 2008)
with depressive symptoms in the elderly a far more common problem than major
depression (Beekman et al. 1995).
Older people risk an insidious slide into low mood exacerbated by age related risk
factors including age-associated neurobiological changes, stressful events such as loss of
partner and peers, social isolation, poverty and insomnia (Fiske et al. 2009). It is therefore
important to look at cost-effective ways in which the psychological wellbeing (PWB) of
the elderly can be maintained or enhanced.
1.1 Defining Wellbeing
Within positive psychology, wellbeing is an outcome of positive emotions and positive
traits, which enable positive experiences, and positive institutions (Seligman 2002).
Wellbeing involves optimal psychological functioning. It is commonly viewed from a
hedonistic or eudemonic perspective. Hedonism (Kahneman et al. 1999) is based on the
experience of physical and mental pleasures and is often described as subjective wellbeing
(SWB). The dominant tradition in positive psychology has been to assess SWB which has
been shown to equate with happiness (Kahneman et al. 1999). It consists of three com-
ponents, the presence of life satisfaction, frequent positive emotions, and infrequent
negative emotions. In contrast eudemonism (Waterman 1993); recognises that fulfilling
pleasurable desires does not always result in wellbeing and so regards PWB as being more
complex than purely SWB. In PWB the focus is on living a meaningful life and developing
one’s full potential. McMahan and Estes (2011) suggested that eudemonic wellbeing may
be relatively more important for positive psychological functioning. However, as hedonia
and eudemonia occupy both overlapping yet distinct niches; greatest wellbeing may be
associated with their combination (Huta and Ryan 2010). It is due to this debate that the
evaluation of the intervention presented here will include SWB and eudemonic measures.
1.2 Dispositional Gratitude and Wellbeing
Based on empirical research, Peterson and Seligman (2004) reported that six virtues
containing twenty-four character strengths are consistently related to life satisfaction and
well-being (Peterson and Seligman 2004). One such character strength located within the
transcendence virtue is gratitude, which from its early roots in theology, has been regarded
as integral to wellbeing (Emmons and Crumpler 2000). Simply expressed gratitude is, ‘‘an
acknowledgement that we have received something of value from others’’ (Emmons and
Mishra 2011). Gratitude is variously conceptualized as a moral virtue, an attitude, an
emotion, a habit, a personality trait, and a coping response (Emmons et al. 2003). Dis-
positional gratitude is assessed on four dimensions, intensity, frequency, span, and density.
948 A. Killen, A. Macaskill
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Individuals high in gratitude experience more intense feelings in response to a gratitude-
arousing situation, notice more occasions to express gratitude, have a wider range of
circumstances for which they are grateful, and experience gratitude towards people more
frequently (McCullough et al. 2002). Gratitude is reported to be the most beneficial
character strength, and is consistently and robustly associated with life satisfaction and
wellbeing (Park et al. 2004).
Gratitude influences wellbeing either directly as a causal agent of wellbeing, or indi-
rectly by buffering against negative states and emotions (Nelson 2009) such as those
experienced as individuals become elderly (Fiske et al. 2009). Enhancing gratitude may
help older people cope with these age-related adversities. This is because gratitude con-
tributes to wellbeing by providing an antidote to stress and helps to develop enduring
personal resources such as resilience (Frederickson 1998; Fredrickson et al. 2003). Better
adjustment in retirement is associated with robust psychological health (Donaldson et al.
2010) and gratitude protects individuals from stress and depression even allowing for
personality factors (Wood et al. 2008a).
Several possible mechanisms to explain the effect of gratitude have been identified.
Expressing gratitude and grateful thinking allow positive life experiences and situations to
be savoured increasing satisfaction with life and building positive strengths (Sheldon and
Lyubomirsky 2006). Adaptation whereby good things become taken for granted is less
likely so positive affect is increased (Lyubomirsky et al. 2005). Gratitude also helps
reframe negative emotional memories decreasing their adverse impact (Watkins et al.
2004). This adaptive coping strategy may reduce stress by allowing stressful or negative
life experiences, to be reinterpreted with a grateful perspective (Wood et al. 2008b).
Positive coping strategies are used more commonly among grateful people (Wood et al.
2007).
Gratitude may also enhance wellbeing through schematic processing. Grateful people
have specific schematic biases towards viewing help as having a higher cost, value, and
involving greater altruism, which may account for them feeling more gratitude following
events where they are given help (Wood et al. 2008b). Additionally, negative emotions
including envy, bitterness, anger, and greed are incompatible with gratitude practises thus
are inhibited in those high in gratitude (Lyubomirsky et al. 2005). Finally, Fredrickson’s
(2000) broaden and build model suggests experiencing positive emotions, such as grati-
tude, undoes the adverse physiological effects of negative emotions. It increases the
flexibility of coping strategies and builds social bonds during less stressful times, which
bolster coping resources.
1.3 Gratitude and the Elderly
McAdams and Bauer (2004) suggest that a sense of gratitude may be particularly important
for older adults in terms of helping people successfully attain the final stage of adult
development and resolve the crisis of integrity versus despair to reach ego integrity
(Erikson 1959). The theory of socioemotional selectivity suggests that older adults may
focus more on the present due to awareness of time being limited. This may lead the
elderly to prioritise experiencing emotional meaning in their relationships, and for this,
maintaining established relationships with their shared history may be more important than
building new ones (Carstensen et al. 1999). Existing relationships possess greater oppor-
tunities for more frequent reciprocal altruism and the associated expression of gratitude for
these acts, so compared with younger adults, older adults may be more likely to view
gratitude as a positive, rewarding, experience (Kashdan et al. 2009).
Gratitude Intervention for Older Adults 949
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Lau and Cheung (Lau and Cheng 2011) in a study of Chinese older adults aged 55–85
used a narrative writing task on experienced life events, with one group writing about
gratitude inducing events, another about hassles, and a third providing neutral descriptions
of life. The results suggested that the gratitude induction writing task reduced death anxiety
more than the hassle and neutral conditions did. They suggested that gratitude is an
important strength to develop for older adults because by re-examining life events with a
grateful attitude, people may become less fearful of death due to a sense that their life has
been well lived. An intervention study involving older adults aged 60–93 years used
training on recalling positive autobiographical memories, exploring gratitude and for-
giveness with exercises involving the production of gratitude and forgiveness letters
(Ramı
´rez et al. 2014). While changes in gratitude were not specifically measured, there
were significant decreases in state anxiety and depression and increases in life satisfaction
and subjective happiness compared with a placebo group. The authors report that the
association of a gratitude intervention with reductions in depression supports the finding of
Seligman et al. (2005) and Gander et al. (2013), although the participants were younger in
these studies. A qualitative interview study exploring successful ageing with 24 commu-
nity-dwelling older people aged between 77 and 90 years, reported that the strategy of
choosing to feel gratitude for what was positive in their lives rather than worrying about
what they cannot change was associated with increased feelings of well-being (Ho
¨rder
et al. 2013).
Researchers are now beginning to examine the biochemical basis of wellbeing and one
study by Barraza et al. (2013) examined the effect of a 10-day trial of the neuropeptide
oxytocin on the wellbeing of a group of 23 community-dwelling elderly people. Oxytocin
is a hormone hypothesized to regulate social processes, particularly the motivation to
socially engage and actual behavioral engagement. Emmons and McCullough (2003)
reported that gratitude appears to motivate social behavior. Barraza et al. (2013) carried out
a randomized trial with participants of mean age 80 years. Dispositional gratitude
improved over the trial period for the experimental group but declined in the control group,
thus providing some support for the hypothesized role of oxytocin on social behavior and
gratitude in particular. Overall, this research attests to the emerging importance of the
contribution of gratitude to wellbeing and provides a strong rationale for evaluating a
gratitude intervention with an elderly population.
1.4 Using Gratitude Interventions to Enhance Wellbeing
Emmons and McCullough (2003) originally described using a gratitude intervention to
enhance wellbeing in their ‘counting blessings versus burdens’ studies. Three randomised
controlled trials demonstrated higher levels of both positive affect and physical benefits.
Students keeping weekly gratitude journals were compared with others recording either
neutral events or negative life stresses. The weekly-gratitude group spent more time
exercising, reported fewer physical symptoms, and felt more optimistic about the future. In
the second study, the gratitude-journal was maintained daily rather than weekly. Findings
showed this group were more enthusiastic, alert and determined and significantly more
likely to progress towards their goals. The third study, compared participants diagnosed
with neuromuscular diseases in gratitude or control conditions. Results showed gratitude
lists were more effective than waiting list controls at improving functioning and mood.
These results need replication with other populations such as the elderly.
Various types of wellbeing interventions including two related to gratitude were
compared in an internet based randomised controlled trial involving nearly six hundred
950 A. Killen, A. Macaskill
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visitors of all ages to a positive psychology website (Seligman et al. 2005). Random
allocation was to one of five happiness exercises or a placebo control exercise. These
included a gratitude visit and a ‘three good things in life’ written exercise involving
documenting three things that went well during the day and their causes, every night for
1 week. Both gratitude intervention groups showed increased happiness and decreased
depressive symptoms at 1 month, continuing for 6 months in the three good things exer-
cise. However, the participants in this sample were interested in positive psychology,
having located the website, which may have influenced the results and the elderly were
under-represented in the sample.
Given that these studies highlight the importance of gratitude, it seems timely to
evaluate a gratitude intervention with a group of elderly participants, given that the
intervention has been shown to be effective with younger populations in promoting
wellbeing even in adversity. There are increasing numbers of the elderly having to cope
with increasing negative events in their lives and related emotions frequently with reduced
capabilities so promoting gratitude would seem a useful intervention.
The ‘three good things in life’ intervention was chosen for its emphasis on rousing
gratitude by focussing on positive events and causes as distinct from gratitude towards an
individual as promoted by a gratitude letter. Expressing gratitude towards an individual
may result in feelings of indebtedness, which can be stressful and could actually diminish
wellbeing through feelings of inability to repay or reciprocate. This may be more likely to
occur in older participants due to their depleted economic or physical resources (Offer
2012). The three good things intervention involves keeping a daily diary in which
respondents identify subjectively assessed positive events in their lives. Based on previous
research with other age groups, it was hypothesised that the intervention would be bene-
ficial in terms of improving well-being.
1.5 Enhancing Wellbeing Online
Costs of interventions especially with large populations such as the elderly are an issue.
Online interventions can be highly cost-effective with larger numbers being treated
compared to traditional therapist led groups. Other advantages include the opportunity to
work at the participant’s chosen speed and time. Additionally, in the authors’ views,
barriers to participation more specific to older people can be overcome by home-based
interventions. These include sporadic attendance from lack of accessible public transport or
inability to continue driving, difficulties leaving caring responsibilities for partners and
reluctance to participate in groups due to hearing loss, stigma among an age group
unfamiliar with engaging with psychological services or unwillingness to congregate with
similarly frail individuals. However, fully self-directed online interventions without human
guidance or contact suffer from high attrition rates (Eysenbach 2005). Attrition from
studies of self-directed therapies for depression can reach 99 % (Christensen et al. 2006).
Younger age was a consistent predictor of attrition from self-directed therapy (Geraghty
et al. 2010) while being older increased the chances of completion of post-intervention
measures (Buller et al. 2008).
While interventions to promote behaviour change are increasingly internet based with
85 such studies identified between 2000 and 2008 (Webb et al. 2010), few online inter-
ventions have targeted older adults specifically although over half of older adult internet
users search for health information online (Huang et al. 2012). Bond et al. (2010) con-
cluded that web-based interventions could be effective in improving older individuals’
PWB. Meta-analysis of fifty-one positive psychology interventions found benefits
Gratitude Intervention for Older Adults 951
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increased linearly with age (Sin and Lyubomirsky 2009). Suggested reasons for this were
that older people treated the interventions with greater seriousness, applied more effort,
and had more effective emotional and self-regulation. However, paper methods are
familiar and accessible to a wider group who lack computer literacy.
Self-guided wellbeing related interventions have been shown to be beneficial whether
completed online (Mitchell et al. 2009) or on paper (Ramachandra et al. 2009). The present
study therefore offered a choice of delivery route in order to address the further research
question of whether different outcomes or experiences resulted when older adults com-
pleted the intervention online or on paper. Based on previous research it was hypothesised
that outcomes would be similar for both routes.
To summarise the study aimed to assess whether a population aged 60 years and over
would benefit from a gratitude intervention. Based on previous research, the hypothesis
was that the intervention would reduce stress levels and improve hedonic and eudemonic
wellbeing. The effects of online and paper delivery were compared and differences in
acceptability of the two routes examined. The hypothesis, based on previous research, was
that there would be no differences.
2 Method
2.1 Participants
Eighty-eight participants were recruited (F =65, M =23) whose ages ranged from
60–91 years (Mean 70.84, SD 7.51). Two participants declined to report their age. They
were recruited from local community organisations for older adults, two branches of the
University of the Third Age (U3A) in the North of England and subscribers to an Elder’s
Council newsletter that represents older people in a city in North East England. While pre-
retirement occupation was not recorded for these participants, these organisations attract
mainly retired professionals (84 % is the national figure), with 31.81 % (N=28) having
university degrees compared with 11.5 % of the general population in that age group in the
UK. All participants lived independently in the community. Only seven of the participants
(7.95 %) did not have a computer, while nationally in the UK, 60 % of population aged
over 65 years do not have computers (UK Office of National Statistics 2013). No payment
was given to participants but a study summary was offered.
Several exclusion criteria were provided in the study advertisement to aid participants’
self-selection. These were lack of English as a first language, a current mental health
diagnosis due to ethical implications associated with using measures focussing on sensitive
topics such as life satisfaction and a diagnosis of memory impairment as the intervention
required daily reflections.
2.2 Procedure
Ethical approval was obtained from the university Research Ethics Committee. Participants
selected the online (N =48) or paper (N =40) version of the study. Online participants
received an e-mail link to the information sheet, study description, and the researchers’
e-mail details for any clarification. Participants were advised that choosing the submit
button after reading these was recognised as providing informed consent but they could log
off before this and no data would be collected. Paper participants received study packs for
completion and return by post. These contained similar information sheets but with postal
952 A. Killen, A. Macaskill
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and telephone contact details for the researchers. Anonymity was maintained by using a
code on each response form and participants were provided with instructions for generating
the code. Participants completed identical baseline questionnaires either online or on paper
containing demographic information, details of their computer use, a health measure and
five measures of PWB. Paper questionnaires were returned in a prepaid envelope.
Every evening for the following 14 days, participants were requested to record briefly in
the ‘three good things diary’ three events occurring that day that seemed positive to them,
and why they viewed them positively. Examples were given for assistance. [14 days were
selected, as a shorter time may be inadequate to develop sufficient skills and expertise
(Seligman et al. 2005)]. Baseline questionnaires were repeated on the day following
completion of this diary exercise (Day 15) and at 30 days post-intervention (Day 45).
Measures were presented in a different ordered to minimise order effects. Additional
qualitative questions addressed difficulties or benefits experienced with the chosen com-
pletion route and asked whether respondents would select the same route in future.
Participants were invited to return their completed diaries. The purpose was to check
task adherence for the specified duration, to confirm whether positive events were reported
and to explore the nature of events experienced as positive by older people.
2.3 Measures
Participants completed the following measures:
The Gratitude Questionnaire (GQ-6) (McCullough et al. 2002). This six-item scale
examines four facets of grateful dispositions, namely, intensity, density, span, and fre-
quency. Responses are recorded on a seven-point Likert scale from 1 (strongly disagree)to
7(strongly agree). Higher scores indicate greater dispositional gratitude. The scale has
acceptable internal consistency (Cronbach’s alpha .82), good convergent reliability with
wellbeing and peer ratings and high test, retest reliability, and discriminant validity from
related traits. (McCullough et al. 2002). The Cronbach’s alpha was .87 in this study.
The Flourishing Scale (FS) (Diener et al. 2010). This eight-item scale measures psy-
chological needs related to eudaimonic wellbeing, including the need for competence and
relatedness. It measures having supportive and rewarding relationships, contributing to the
happiness of others, and being respected by others, assessed on a seven point Likert scale
from 1 (strongly disagree)to7(strongly agree). The scale has good psychometric prop-
erties, (Cronbach’s alpha [.80, convergent validity shows correlation at high levels with
other wellbeing measures, such as the Basic Needs Satisfaction Scale, and Satisfaction
with Life Scale (Diener et al. 2010). High scores represent individuals with many psy-
chological resources and strengths. The Cronbach alpha here was .95.
The Satisfaction with Life Scale (SWLS) (Diener et al. 1985). This five-item scale
assesses global judgment of life satisfaction, as the cognitive aspect of subjective well-
being using a seven-point Likert scale from 1 (strongly disagree)to7(strongly agree).
Higher scores reflected more satisfaction with life. The SWLS demonstrates high internal
consistency (Cronbach’s alpha .87), and 2-month test–retest reliability (r=.82), (Diener
et al. 1985). It demonstrates good discriminant validity from other measures of SWB and
the more cognitive traits of self-esteem and optimism (Lucas et al. 1996). The Cronbach
alpha was .96 in this study.
The Scale of Positive and Negative Experience (SPANE) (Diener et al. 2010). The scale
comprises twelve items assessing a broad range of negative and positive experiences and
feelings. Six items relate to positive and six to negative experiences, providing two sub-
scales, scored separately because of the partial independence of the two types of feelings
Gratitude Intervention for Older Adults 953
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(Diener et al. 2010). Scoring is based on frequency of experiencing feelings, ranging from
1(very rarely or never)to5(very often or always). Subtracting the negative score from the
positive score gives a balance score. The SPANE shows good psychometric properties;
(Cronbach’s alpha .81–.89) and performs well in reliability and convergent validity with
other measures of emotions (Diener et al. 2010). In this study the Cronbach’s alphas were
positive affect =.96 and negative affect =.91.
The Perceived Stress Scale (PSS10) (Cohen and Williamson 1988). This is a measure
based on the PSS14 (Cohen et al. 1983) with improved internal validity over the original. It
provides a global measure of the degree to which situations in life are appraised as stressful
rather than reactions to specific stressful events and so is sensitive to chronic stress from
on-going life circumstances and stress from expectations concerning future events. It
assesses the extent to which respondents find their lives unpredictable, uncontrollable, and
overloading, all issues forming the central components of the stress experience (Cohen
et al. 1983). Although the PSS shows high correlation with depressive symptomology
scales, it has been shown to measure a different, independently predictive construct.
Participants respond to ten questions on a 5-point Likert scale from 1 (never)to4(very
often). Higher scores reflect greater levels of perceived stress. The study Cronbach alpha
was .94.
The Centres for Disease Control and Prevention (CDC) Health Related Quality of Life,
HRQOL–14 ‘‘Healthy Days Measure’’. This assesses physical and mental health over the
past thirty days. It contains a 4-item Healthy Days Core Module totalling physically and
mentally unhealthy days. The 5-item Activity Limitation Module (CDC 2000) asks about
presence, duration and need for care related to the major health impairment experienced.
The CDC 5-item Healthy Days Symptoms Module (CDC 2000) asks about recent days
affected by symptoms of pain, depression, anxiety, sleeplessness, and energy. The ques-
tionnaire has criterion validity with respect to the Medical Outcomes Study Short Form 36
(Andresen et al. 1999) and Newschaffer (1998) reports good construct validity.
Participants were asked if they intended to continue with the intervention at the end of
the intervention. They were also asked about their level of computer use and what which
delivery route they would prefer in future for such an intervention with options being
online, paper, or no preference and text boxes were supplied for any explanations.
2.4 Data Analysis
Preliminary analyses included descriptive statistics for demographic and health data and
the five wellbeing measures. Prior to computing a repeated measures doubly-multivariate
analysis of variance, the dataset was screened for normality, linearity, univariate and
multivariate outliers, multicollinearity, homogeneity of variance–covariance matrices and
no serious violations were noted. There were no outliers but there was a tendency towards
skewness, however Tabachnik and Fidell (2012) suggest that the F-test in MANOVA is
robust to non-normality especially if this is due to skewness rather than outliers as in this
instance. To deal with unequal samples sizes a Pillai’s trace statistic was used. An alpha
level of .05 was used for statistical tests. To minimise multicollinearity, the subscales of
the SPANE were not included in the analyses, but only the emotional balance calculation.
This is also in keeping with the measurement of well-being where emotional balance is the
important concept. The dependent variables were gratitude, flourishing, life satisfaction,
emotional balance and perceived stress. The independent variable was completion route
(online/paper) and the measures were repeated at three times points. Mean differences were
computed on all the variables where there were significant differences across time using
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Hochberg criteria as the group sizes were unequal. The health quality of life data was only
collected, as baseline demographic information so was not included in the statistical
analysis.
Thematic analysis was conducted to interpret the diary data and the qualitative ques-
tions (Clark and Braun 2006). This seemed appropriate given the magnitude of the data and
that it was clearly structured as responses to specific questions.
3 Results
3.1 Health Data and Descriptives
In all, 87 diaries were returned from the 88 participants demonstrating that respondents had
complied with the instructions and successfully identified positive events and causes. Self-
reported health was mainly ‘good ‘or ‘very good ‘. Only 15 % of participants described
their health as ‘fair’ or ‘poor’. Participants also reported the number of physically or
mentally unhealthy days experienced in the previous month, with 46.6 % reporting no
unhealthy days, 34.1 % had less than ten unhealthy days and 19.3 % described ten or more
unhealthy days. Table 1includes descriptive statistics for all the measures. Baseline mean
perceived stress scores at 11.87 (5.87) showed comparable results with US data collected in
2009 (Cohen and Janicki-Deverts 2012) reporting 11.09 (6.77) in a population aged 65 and
over. The means, and standard deviations for each variables for the online and paper routes
and the total sample at baseline (day 1), end of the intervention (day 15) and at follow-up
(day 45) are presented in Table 1. Age related population means were unavailable for the
other measures.
Table 1 Means, standard deviations and ranges for gratitude, flourishing, life satisfaction, SPANE and
perceived stress, across time by paper (N=40) or online (N=48) completion route and for the total
sample (N=88)
Scale (range) Day 1
M (SD)
Day 15
M (SD)
Day 45
M (SD)
Total gratitude (6–42) 34.56 (4.71) 34.23 (5.05) 34.29 (5.98)
Paper 35.35 (4.70) 34.40 (4.94) 35.37 (6.19)
Online (N=48) 33.90 (4.67) 34.08 (5.18) 33.58 (5.27)
Total flourishing (8–56) 44.28 (6.78) 46.06 (6.08) 45.49 (6.39)
Paper 43.93 (7.66) 45.83 (6.37) 46.00 (6.44)
Online 44.58 (6.02) 46.25 (5.89) 45.16 (6.40)
Total life satisfaction (5–35) 24.78 (6.46) 24.83 (7.12) 25.29 (6.54)
Paper 24.93 (6.03) 24.90 (6.94) 24.70 (6.83)
Online 24.67 (6.86) 24.77 (7.34) 25.69 (6.39)
Total SPANE balance (-24 to 24) 9.59 (6.79) 10.50 (6.41) 11.20 (7.62)
Paper 10.85 (6.16) 12.40 (5.90) 11.33 (8.25)
Online 8.54 (7.17) 8.92 (6.43) 11.11 (7.27)
Total perceived stress (0–40) 11.88 (5.87) 10.40 (5.52) 11.36 (6.47)
Paper 10.85 (4.94) 9.60 (5.12) 11.10 (6.47)
Online 12.73 (6.47) 11.06 (5.81) 11.53 (6.67)
Gratitude Intervention for Older Adults 955
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3.2 Analysis of Intervention Data
To analyse the effect of the intervention, data was analysed using a Repeated Measures
Doubly-Multivariate Analysis of Variance, with two groups defined by completion mode
(paper or online) who completed measures of flourishing, gratitude, life satisfaction
(SWLS), emotional balance (SPANE), and perceived stress, at 3 time points (Days 1, 15,
and 45). Initially age and sex were included in the analyses but as no statistically signif-
icant age or sex effects were found, these variables were dropped from the subsequent
analyses to increase power. Using Pillai’s trace as a conservative test, as group sizes were
unequal there was no statistically significant difference in online versus paper completion
routes, F(5, 69) =2.11, p=.07. There was a statistically significant difference across the
three time points, F(10, 64) =4.04, p=.001, partial eta squared =.39 and the time by
route of completion interaction was significant F(10, 64) =2.31, p=.02, partial eta
squared =.27.
Examining each measure across time, the univariate results using a Bonferroni cor-
rection in SPSS, showed that there were statistically significant differences in flourishing
across the three time points F(2, 146) =7.84, p=.001, partial eta squared =.10 and
perceived stress F(2, 146) =4.10 p=.02, partial eta squared =.05. SPANE balance
scores approached significance F(2, 146) =2.79, p=.06, partial eta squared =.04. For
flourishing, 10 % of the variation in error score was accounted for by completion day, with
significant increases in flourishing scores between Day 1(M=44.28.5, SD =6.78) and
Day 15 (M=46.06, SD =6.08), SE =.54, p=.002, 95 % CI [-3.24, -.62]. The dif-
ferences in mean flourishing scores between day 15 (M=45.83, SD =6.37), and day 45
(M=45.49, SD =6.39) were not significant. However, the differences in mean flour-
ishing scores between day 1 (M=44.28.5, SD =6.78), and day 45 (M=45.49,
SD =6.39) were significant, SE =.49 p=.04, 95 % CI [-2.45, -.04].
With perceived stress 5 % of the variation in error score was accounted for by com-
pletion day, with significant decreases in perceived stress scores between Day
1(M=11.88, SD =5.87) and Day 15 (M=10.40, SD =5.52), SE =.42, p=.003,
95 % CIs [.43, 2.49]. The differences in scores between day 15 and day 45(M=11.36.,
SD =6.47) and day 1 and day 45 were not statistically significant.
Exploring the time by route interactions for each measure indicated that the only sig-
nificant differences were on the SPANE balance scores F(2, 146) =4.09, p=.02, partial
eta squared =.05. The differences in scores between the online and paper completion
routes for SPANE balance were not significant on day 1 or day 45 but at day 15, the scores
of the paper group (M=12.40 SD =5.90) were significantly higher than those of the
online group (M=8.92, SD =6.43), t(85) =2.36, p=.02) 95 % CIs [.53, 6.2].
3.3 Confirmation of Positive Events
A possible disadvantage with the self-directed nature of this intervention was that iden-
tified events might not actually be positive resulting in an events record without any
positive reflections, which would be unlikely to enhance wellbeing. Analysis of the diaries
confirmed compliance with the intervention and positive events were described. Content
analysis identified six dimensions of successful positive psychological functioning com-
prising; self-acceptance, positive relations with others, autonomy, environmental mastery,
purpose in life, and personal growth. Examples of positive experiences and their causes
related to these themes are illustrated in Table 2.
956 A. Killen, A. Macaskill
123

Many of the positive experiences fitted the components of the eudaimonic multidi-
mensional model of PWB being activities that contribute to a meaningful life, maintain
independence, and helping others (Ryff and Keyes 1995).
3.4 Intention to Continue
Eighty per cent did not plan to keep a gratitude diary in the future, 8 % had continued and
12 % said they planned to start after they had finished the study. Planned or confirmed
continuation was similar for online (N=8) and paper (N=7) participants. An ANOVA
comparing the day 45 mean scores on all the variables between this group and those not
continuing with the intervention found no significant differences between the two groups.
3.5 Views on Delivery Route
No barriers to participation with the online method were identified, with 60 % of online
respondents saying they would choose this method again (21 % no preference, 19 %
paper). Among paper respondents 15 % said they would try online (73 % paper, 12 % no
preference). Reasons for choosing the online route were based around ease and legibility:
Table 2 Content analysis of diary entries
Theme Positive experience and (cause)
Autonomy I put my wheelie bin out and brought it back in after the refuse men had been. (One
of my sons has been doing this. I felt more independent being able to do it
myself.) (Frances 75)
A button had come off my cardigan and I sewed it back on. (My eyesight isn’t
good and my hands are shaky but I still did it!) (Arthur 91)
I accepted an invitation to talk to a group about arranging finances. (It felt good to
use my experience to help others). (Laura 73)
Positive relations with
others
Cooking a meal for my grandson to help out my daughter. (The most positive part
was when he said, ‘‘Thanks Grandma, that was great’’). (Mary 76)
Purpose in life Visited the local butcher and shopping area. (I am trying to keep local shops open
to stop this small area from dying). (Jan 74)
Went on the anti-cuts march in London. (This Government is destroying the very
foundations of our society, we can do something if we demonstrate we do not
support them.) (John 77)
Personal growth Completing a pastel painting of fruit. (I was always told I had no artistic talent and
I was pleased with what I produced). (Jen 65)
Talked to year 10 pupils about HIV/AIDS. (My daughter died unnecessarily and in
fear of AIDS. I need to make some sense of the senseless and it allows me to talk
positively about my daughter). (May 66)
Environmental
mastery
Found out a lot about which TV to consider buying and what not to be. (Went to
TV department as part of my shopping research and was helped by someone who
answered all my questions). (Elaine 62)
Went to the supermarket early. (Glad to have gone before the rush and
remembered everything). (Sue 63)
Self-acceptance Weighed myself. (Very pleased to see that despite far too many nuts and fat too
much chocolate and biscuits, I have managed to remain at 8 and a half stones).
(Barbara 65)
Knees aching while shopping. (Saw someone walking with a stick and thought,
‘‘well at least I can still walk’’). (Dot 73)
Gratitude Intervention for Older Adults 957
123

It’s quick, convenient, and not likely to get lost in a heap of papers in the house
(Marion 62)
Online is much quicker, and any written material is legible (John 71)
In addition to word processing, questionnaire completion required further computer
interaction but the completion accuracy did not differ between the online and paper groups.
Many of the paper participants did use computers with 55 % reporting using one for at
least 1 h a day. This compared with 83 % using a computer for at least an hour a day for
online participants. Only 18 % of the sample reported that they never used a computer
although some had a computer in their homes as only seven participants did not have a
computer. Comments regarding preferences for using paper were that using the computer
felt like a work task and required them to sit at a desk in a study. There seemed little
awareness of the flexibility of portable devices such as tablets and laptops for completion
of this type of task.
I can fill in the diary away from the computer instead of upstairs in the workroom
(Pat aged 69)
Some participants expressed anxiety about making errors online:
Paper methods give everybody an equal opportunity, my computer is my unpre-
dictable ally not my friend (Doris 67)
4 Discussion
The 2-week gratitude intervention was effective in increasing aspects of well-being in this
relatively healthy elderly population with statistically significant increases in flourishing
and decreases in perceived stress. There was no significant differences between paper and
online delivery overall, although there was a significant interaction between time and route
of completion. This was accounted for by the paper group having significantly higher
scores on emotional balance than the online group at the end of the intervention although
overall the levels of emotional balance did not change significantly across the time of the
intervention and follow-up. Content analysis of the positive events in completed diaries
confirmed that the intervention was being implemented appropriately. Collecting this data
does not appear to be standard practice yet in this study it provided interesting data as well
as a reliability check on the contents of the intervention.
Flourishing scores increased significantly between day 1 and day 15, the end of the
intervention, for the total sample regardless of whether the intervention was completed
online or on paper. Flourishing scores at the 45-day follow-up remained very similar to the
day 15 scores evidencing that the increases were still being maintained 30 days after the
end of the intervention. Overall, the intervention significantly increased flourishing in this
elderly sample with scores at day 45 being significantly higher than at the start of the
intervention.
The concept of flourishing relates to the fulfilment of psychological needs related to
eudemonic wellbeing, such as the presence of supportive and rewarding relationships,
contributing to the happiness of others, being respected by others and feeling competence
and a sense of autonomy (Waterman 1993). The six dimensions representing the events
that the research participants identified as positive in their practice of gratitude fulfilled
many of the flourishing criteria. Competence and feelings of autonomy were apparent in
958 A. Killen, A. Macaskill
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the 91-year-old man who was sewing on buttons despite his physical frailties or the woman
putting out her own refuse. Supportive and rewarding relationships were apparent in
assisting with childcare and sharing their expertise and experiences with others and being
helped by others as well. Other themes related to having a purpose in life and thus
contributing to the wellbeing of others, be it by keeping neighbourhood shops open or
participating in political protests. While many of the examples were ordinary events, the
explanations indicate how important their achievements were for these individuals, they
were life-affirming experiences, showing that they still mattered and were of value. This
would seem to link to the requirements for the attainment of ego integrity that Erikson
(1959) discusses and the self-acceptance dimension reinforces this interpretation. The
intervention can be conceptualised as requiring individuals to become more mindful of
events in their daily lives and recognise the positive aspects in the everyday, being grateful
for what they can experience, contribute, and achieve. These findings provide tentative
support for the contention that experiencing gratitude may be particularly important for
older adults seeking to reach ego integrity and could be examined in more depth in the
future (McAdams and Bauer 2004).
Other researchers have similarly demonstrated the importance of gratitude exercises in
increasing wellbeing in elderly populations but they used different interventions and
wellbeing measures. This appears to be the first study measuring flourishing in an elderly
population. The results are similar to those obtained with much younger participants by
Wood et al. (2010). Lau and Cheng (2011) reported that a gratitude inducing writing task
reduced death anxiety in elderly Chinese participants. The suggestion was that bringing a
positive focus to narrating life events provides a sense to individuals of their life being
meaningful and well lived. This is similar to the process reported in the qualitative analysis
of life events in this study.
Ramı
´rez et al. (2014) found reductions in anxiety and depression after elderly partici-
pants wrote letters expressing their gratitude to other. Ho
¨rder et al. (2013) in a qualitative
interview study with community-dwelling older people reported that focusing on feeling
gratitude for what was positive in their lives rather than worrying about what could be
changed was associated with increased feelings of well-being. This again is similar to the
activities reported by participants in the gratitude intervention reported here and produces
similar benefits.
Perceived stress scores significantly reduced over the course of the intervention but this
reduction was not maintained at follow up with scores returning close to those at the
baseline. The link between the gratitude intervention, stress reduction and increases in
flourishing supports the contention that gratitude may influence wellbeing by buffering
against negative states and emotions (Frederickson 1998; Fredrickson et al. 2003; Nelson
2009; Wood et al. 2008a). The increase in reported perceived stress at follow-up in this
study, suggests that it is important to continue actively practising the gratitude intervention
if any stress buffering effect is to occur. Frederickson (1998) suggested that the practice of
gratitude should lead to greater resilience against adversity and this would be worth
examining a future study. It would be useful to determine how long these interventions
need to be for greater resilience in the face of stress to emerge.
Fredrickson et al. (2003) propose that positive affect will also increase because of the
experience of a positive emotion such as gratitude. However, there were no significant
increases in emotional balance over the course of the gratitude intervention in our study.
The paper delivery group had significantly higher scores on emotional balance at the end of
the intervention than the online group although the increase from baseline scores was not
significant for either group. This is not easy to explain. Some participants in the online
Gratitude Intervention for Older Adults 959
123

group reported they while they used computers, they were not totally at ease with them and
sometimes became frustrated when online. It may be that such computer problems, or
apprehension about using a computer affected the emotional balance results for some
online participants and future research could examine this in more detail.
Delivering the intervention online or via the more traditional paper route did not sig-
nificantly affect the results with both routes appearing equally efficacious. This successful
delivery of the intervention with minimal contact between researcher and participants
reinforced findings obtained from studies with younger populations that a therapeutic
alliance is not essential to produce beneficial effects (Seligman et al. 2005). This allows for
cost effective delivery of such interventions. The results suggest that online participation is
not disadvantageous for this age group compared to the traditional paper route. Online
participants confirmed a willingness to engage with the computer as a tool for a therapeutic
exercise. While many older adults have excellent computer literacy skills, awareness of
potential difficulties they might face online is essential to facilitate uptake and compliance.
This may include accommodating declining vision, hearing, and psychomotor coordination
by using larger font sizes, considering the frequency range of any sounds and using layouts
that need less precise mouse movements (Hawthorn 2000).
Although the intervention was focussed on inducing gratitude, actual gratitude scores
barely changed across the time of the intervention. This may be unimportant if as shown
respondents experienced enhanced wellbeing through increased awareness of the things
and people that made them feel grateful. Gratitude is a dispositional measure, so only small
increases on the gratitude scale were anticipated. However, the scores showed a minimal
decrease that could have been due to ceiling effects from very high baseline scores.
Alternatively, in some participants, the effect of reflecting on gratitude may have produced
slightly negative effects from feelings of indebtedness that can be associated with feelings
of guilt (Watkins et al. 2006).
While the subjective well-being measures of life satisfaction and emotional balance
increased over the intervention they increases were not statistically significant. It appears
that the intervention was more effective at increasing eudemonic wellbeing. As discussed
earlier the six dimensions identified in analysis of daily positive events and why they were
positive seems to support this.
Increases in wellbeing are highest when an activity is a good fit with a participant’s
personality and they enjoy completing it (Sheldon and Lyubomirsky 2006). The vast
majority of respondents in the present study complied with the instructions but occa-
sionally comments were made that less than three examples could be identified for that
day. Additionally some respondents may have been bored by daily entries while for some
14 days was insufficient to develop the habit of grateful thinking. When considering the
efficacy of gratitude interventions Lyubomirsky et al. (2005) report that counting blessings
once a week may be more beneficial for wellbeing enhancement compared engaging in the
same behaviour three times a week and suggest that the exercise may become less
meaningful with frequent repetition. Future interventions might allow participants the
freedom to tailor the intervention to personal style in terms of frequency of completion and
number of grateful episodes recorded.
4.1 Limitations
The recruitment methods resulted in participants of above average education and socio-
economic status and this may limit generalizability. However, given the high computer
ownership in this group, compared with the general population in the same age range, this
960 A. Killen, A. Macaskill
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population is a likely target for online health interventions. While a 30-day follow-up
seemed reasonable for retaining participants, a longer follow up would be desirable as
previous interventions using a 1-week diary showed benefits continued to improve at 3 and
even 6 months (Seligman et al. 2005). To ensure reliable results Bonferroni corrections
were used but these can be regarded as over conservative (Streiner 2009).
4.2 Implications and Conclusions
Older adults who are generally physically well and therefore not in regular contact with
health professionals may attribute any insidious drop in feelings of wellbeing to ageing or
may fail to identify a decline. This intervention could be promoted as an opportunity for
people to enhance their own mental health resources for healthy ageing.
Concentrating solely on statistical significance is inappropriate because it is unclear
what numerical or percentage change equates to a discernible experiential difference in
wellbeing or whether a similar rise from a lower baseline is more beneficial than when a
score already approaches the maximum. The clinical relevance of small increases should
be considered and this is demonstrated by the decision of some respondents to continue
with the diary as they found it beneficial. However, continuation could indicate a desire to
please the researchers, as there were no significant differences between these participants
and those not continuing with the intervention.
The strength of the present study is that it provides support for an inclusive and effective
approach towards improving and maintaining optimum levels of wellbeing as aging pro-
gresses. Beneficial outcomes have been demonstrated using both online and paper routes
for self-directed delivery. The findings of this study suggest that the three good things
gratitude diary can enhance eudemonic wellbeing and reduce perceived stress in a popu-
lation of older adults.
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