positive psychology interventions literature review

• Research article
• Open access
• Published: 06 August 2021

Mindfulness-based positive psychology interventions: a systematic review

• Joshua George Allen   ORCID: orcid.org/0000-0001-9662-9863 1 ,
• John Romate   ORCID: orcid.org/0000-0003-0487-7849 1 &
• Eslavath Rajkumar   ORCID: orcid.org/0000-0002-3012-0391 1  

BMC Psychology volume  9 , Article number:  116 ( 2021 ) Cite this article

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There are hundreds of mindfulness-based interventions in the form of structured and unstructured therapies, trainings, and meditation programs, mostly utilized in a clinical rather than a well-being perspective. The number of empirical studies on positive potentials of mindfulness is comparatively less, and their known status in academia is ambiguous. Hence, the current paper aimed to review the studies where mindfulness-based interventions had integrated positive psychology variables, in order to produce positive functioning.

Data were obtained from the databases of PubMed, Scopus, and PsycNet and manual search in Google Scholar. From the 3831 articles, irrelevant or inaccessible studies were eliminated, reducing the number of final articles chosen for review to 21. Interventions that contribute to enhancement of eudaimonia, hedonia, and other positive variables are discussed.

Findings include the potential positive qualities of MBIs in producing specific positive outcomes within limited circumstances, and ascendancy of hedonia and other positive variables over eudaimonic enhancement.

In conclusion, exigency of modifications in the existing MBIs to bring about exclusively positive outcomes was identified, and observed the necessity of novel interventions for eudaimonic enhancement and elevation of hedonia in a comprehensive manner.

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Background of the study

Mindfulness, a practice of conscious non-judgmental awareness to the present, emerged in the Indian subcontinent approximately 2500 years ago [ 1 ]. Around four decades back, with the pioneering works of Kabat Zinn who had incorporated mindfulness into psychotherapy, the scientific application of mindfulness for health and well-being for specific contextual needs had started [ 2 ]. Since then and particularly in the last decade, academic interest in the area of mindfulness has been increasing and the applicability of mindfulness in various facets of life is also getting attention [ 3 , 4 , 5 , 6 , 7 , 8 ]. Most of the accessible Mindfulness-Based Interventions (MBIs) are either standalone therapies or facilitating therapies for various clinical disorders and problems. Although mindfulness contributes immensely to clinical psychology, the concept of mindfulness has a broader and vaster meaning, beyond clinical symptom reduction and toward positive human functioning and flourishing. In recent years, Positive Psychology Interventions (PPIs) that integrate mindfulness elements have shown some promising outcomes [ 1 , 9 , 10 ]. Still, there is a significant lack of clarity in the implementation of Mindfulness-Based Positive Psychology Interventions (MPIs) and their impact on positive human functioning. Hence the current study aims to find and analyze the mindfulness-based interventions from the existing literature which have also shown potentials to be a positive psychology intervention.

Beginning from Mindfulness-Based Stress Reduction (MBSR) proposed by Kabat Zinn in the 1970s, MBIs are mostly used in the clinical settings for managing disorders and supporting prognosis of disorders and diseases. As an attempt to balance this reductionist deficit-model of health, the well-being outcomes of MBIs are also studied, especially in recent years. A positive psychology intervention is defined as “an intervention, therapy, or activity, primarily aimed at increasing positive feelings, positive behaviors, or positive cognitions, as opposed to ameliorating pathology or fixing negative thoughts or maladaptive behavior patterns” [ 12 ]. In this context, an MPI is “a mindfulness-based intervention with the primary aim to enhance positive human functioning”. PPIs not only exert impact on positive variables, but also are effective among clinical populations—as standalone therapies or facilitating interventions—such as the individuals suffering from depression [ 11 , 12 ], affective disorders [ 13 ], generalized anxiety disorder [ 14 ], and eating disorders [ 15 ]. Apart from that, regardless of the nature of population, PPIs have the potential to enhance positive cognition, positive affect, positive behavior, and overall positive functioning and experiences. Integrating positive psychology with mindfulness, or accommodating mindfulness elements in psychotherapy, a number of MBIs are developed, however, the existing literature is insufficient to articulate the quality and quantity of the researches on MPIs. In order to fill this gap, research on the current status of MPIs is warranted.

Furthermore, well-being mainly consists of hedonia and eudaimonia, two highly correlated but distinct forms of well-being, with different characteristics [ 16 , 17 ]. Though they are not mutually exclusive or antagonistic to each other, their nature, intensity, and patterns of expression are singular. This paper attempts to consolidate major mindfulness-based interventions devised for the enhancement of positive functioning beyond clinical symptom reduction, with a given priority to determine the status of MPIs for eudaimonic enhancement. Secondary importance is given to MPIs or MBIs for hedonic well-being and other positive psychology variables such as hope, happiness, resilience, gratitude, flow, compassion, and improved psychological performance. Studies, where a positive psychology variable was just one among three or more dependent variables, were excluded due to their orientation toward the deficit model rather than to positive psychology.

The positive potentials of mindfulness

Eudaimonic enhancement.

Eudaimonia is originally a Greek term that can be translated from a subjective perspective as “happiness”, and from an objective point of view, as “flourishing” [ 18 ]. Broadly, eudaimonia is “the pursuit, manifestation, and/or experience of virtue, personal growth, self-actualization, flourishing, excellence, and meaning” [ 19 ]. The “mindfulness-to-meaning theory” proposed by Garland et al. [ 20 ], advocates that mindfulness broadens the awareness spectrum resulting in cognitive-reappraisal of events to include the positive possibilities of specific instances, that enable the individual to perceive the meaning and purpose of life experiences. The cumulative effects of meaningful positive experiences bring about eudaimonic well-being. And unlike hedonia, eudaimonia will gradually expand on its own without the support of any external agencies, and its possibilities are literally infinite. This nature of eudaimonia is elucidated by the concepts of “eudaimonic staircase” [ 21 ] and the “upside spiral of positive emotions” described in the broaden-and-build theory [ 22 ]. Thus, this review is expected to be a beneficial contribution to the existing scientific knowledge on the role of MBIs in utilizing the eudaimonic-enhancement capability of mindfulness. In addition, recognition of the current utility spectrum of MBIs would support better usage of those MBIs as eudaimonic enhancement tools, or signify the need of further explorations on MBIs for eudaimonic enhancement.

Hedonic enhancement

Hedonia or hedonic well-being shall be defined as “the pursuit and/or experience of pleasure, enjoyment, comfort, and reduced pain” [ 19 ]. Since pain reduction is an element of hedonia, all kinds of psychotherapies are, in a sense, involved in the augmentation of hedonic well-being. Along with eudaimonia, hedonia contributes to subjective well-being [ 18 ]. The efficacy of MBIs is associated with fulfillment of hedonic needs. Some studies have explored the relationship between mindfulness and hedonic well-being and confirmed the assumption that mindfulness functions in direct and indirect ways to induce pleasure and reduce pain [ 23 , 24 ]. Other than clinical symptom management, hedonia and its components can be induced by MBIs, independently as well as in combination with other positive variables. Enhancement of enjoyment [ 25 ], happiness [ 26 ], and positive affect [ 27 , 28 ] are a few examples. Although not always directly stated, improved hedonia—reduced pain and discomfort or improved pleasure and comfort—had been described in clinical literature where MBIs are utilized for therapeutic purpose. The existing literature recognizes the hedonic enhancement quality of mindfulness, but they are not being studied comprehensively. Hence, this review gives auxiliary importance to narrate the MBIs that produced hedonic well-being.

Increasing other positive outcomes

Theoretically and empirically, mindfulness is found to be connected with a number of positive psychology variables. Different MBIs often focus on a specific aspect such as compassion, relaxation, and cognitive skills. Literature suggests that MBIs are effectual in generating a number of positive outcomes such as hope [ 29 ], optimism [ 30 , 31 ], prosocial behavior [ 32 ], flow [ 33 ] working memory [ 34 ], and academic performance [ 35 ]. This paper also reviews MBIs that had produced positive outcomes in addition to eudaimonic and hedonic well-being, in expectation of identifying the extent of impact conceivable for an MPI.

Purpose of the study

This paper attempts to present a narrative/descriptive synthesis of the major MBIs with positive potentials. Firstly, it intends to identify standardized or empirically validated MPIs. Secondly, MBIs that produce positive functioning shall be recognized and their efficacy as an MPI will be verified. Further, the MBIs that improve hedonic well-being and/or other positive variables will also be reported. Finally, the study stands to recount the intention of MBIs in eudaimonic enhancement.

Data were drawn from three electronic databases—PubMed, Scopus, and PsycNet—and a manual search in Google Scholar, from the inception to 29 May 2020. Keyword string used for database search was “mindfulness intervention” and filters were “controlled clinical trials” and “randomized controlled trial” in PubMed; “articles” and “psychology” in Scopus; and “articles” in PsycNet.

Eligibility criteria

The inclusion criteria were: (i) studies with the application of mindfulness-based intervention regardless of the population characteristics such as age, gender, and ethnicity; (ii) experimental and quasi-experimental studies that compared the outcomes between individuals administered with and without an MBI; and (iii) studies with positive psychology variables as dependent variables. The exclusion criteria followed to eliminate the articles were: (i) review papers, (ii) medical/ neuropsychological researches, and (iii) studies with positive psychology variables as just one among three or more dependent variables.

Positive psychology outcomes considered included but not limited to general well-being, eudaimonic well-being, hedonic well-being, happiness, hope, grit, loving kindness, gratitude, empathy, and flourishing. Studies where positive psychology variable was just one among the three or more dependent variables were excluded. It was because the focus of the current research was to find the MBIs that produced positive psychology variables as outcomes (or positive outcomes); and due to the dichotomous nature of many psychological variables, they have a positive and negative continuum which can be reported as the presence or absence of either positive or negative end. If three or more dependent variables are assessing clinical or non-positive conditions, it is highly likely that the one positive variable among these is the absence of a clinical condition rather than a positive psychology outcome. For instance, well-being is often reported as the absence of a clinical condition such as anxiety or depression. Also, when majority of the outcome measures are related to non-positive variables, the intervention is less likely to be developed for positive impacts. Including such studies would redirect the focus of the study and unnecessarily increase the time, energy, and resources for conducting the research.

Review papers were excluded because the study focused on original researches that reported outcomes of an MBI. Papers on medical/ neuropsychological researches were also excluded because their focus was not identification of positive psychology variables as the outcome measures of MBIs. Rather than the physiological mechanisms behind exposure to an MBI, the current study focused on perceived enhancement of positive psychology variables.

Data collection

A complete database search on PubMed, Scopus, and PsycNet was carried out along with a manual search in Google Scholar (see Fig.  1 ). From the four electronic databases, 5045 articles were found, whose titles and abstracts were transferred to the reference management software Zotero on 29 May 2020. After elimination of duplicates, 3377 articles remained. The first author had screened the articles and removed 3234 articles that did not meet the inclusion criteria, leaving 143 articles for full-text review. In the list of 143 articles two articles were rejected due to unavailability of full-text. Rest of the 141 articles were scrutinized and 120 articles were removed that met the exclusion criteria—being review/meta-analytic papers, medical/ neuropsychological researches, or studies where positive psychology variables were just one among three or more dependent variables. At the first stage of elimination, the third author had verified 30% of the randomly chosen articles, and at the second stage of elimination the second and third authors had randomly chosen 30% of the full-text articles and cross-verified, after which 100% of consensus was confirmed regarding the exclusion and inclusion of the articles. Finally, 21 articles that reported an MBI with an anticipated impact on positive variables were chosen for the review. Risk of bias tool of Cochrane (2019 version) [ 36 ] was used to identify risk of bias of the finally chosen articles. In order to reduce any bias during the process of quality assurance, all of the authors had independently applied the tool among all the chosen studies. Except minor differences of opinion, which were resolved through references to literature and open discussions, no major conflicts had occurred. Studies were found to have low risk or some concerns, and none of the chosen studies had shown high risk.

PRISMA flow diagram [ 65 ]

Among the 21 articles analyzed, 22 studies were identified, out of which two studies consisted of clinical populations and 20 different normal populations. Collectively, these 22 studies had assessed the impact of the intervention on 134 dependent variables, and 105 of these were positive aspects (eudaimonia and related aspects = 65, hedonia and related variables = 8, general well-being = 7, other positive psychology variables = 25). The finally chosen studies showed a high heterogeneity in terms of research designs, types of intervention, and outcome measures, due to which a narrative/ descriptive synthesis of the data was employed. Table 1 shows the list of studies as indicated by the author name(s) and year of publication, subsequent research designs, sample size, intervention, dependent variables, duration of the intervention, the population to whom the intervention was administered, and the major findings related to the intervention. As per the aim of this review, scope of data analysis is limited to identification of interventions as MPIs or MBIs with expected impact on positive variables. The paper describes the results of the studies as it is reported by the authors. There is scope for further studies to verify the efficacy of the interventions and whether they would produce the positive outcomes they intended to generate or capable of generating.

Interventions and procedures

A brief account of the interventions, research design, and procedures are described in this section. Studies are categorized based on the nature of the interventions, aiming to convey better meaning of the elaborate narration. This section aims to identify the MBIs that have the potential to be an MPI. And the next section, ‘Outcomes of MBIs’, deals with categorizing studies based on the intention of the intervention to enhance eudaimonia or hedonia and other positive variables. Here, depending on the nature of the intervention, they are categorized into eight: (1) Psychotherapies, (2) MBIs for children, (3) Mindfulness apps (4) Positive Relationships, (5) Mindful Self Compassion, (6) Loving Kindness Meditation, (7) MBIs that may act as MPIs and (8) MPIs.

Psychotherapies

MBIs are commonly used as therapeutic strategies, even when the positive outcomes are being explored. In such a study, Nyklícek & Kuijpers [ 28 ] had applied the MBSR intervention among distressed adults using a randomized waitlist controlled trial. The study intended to find out if the effect of MBSR on stress, vital exhaustion, positive affect, negative affect, quality of life, mindfulness, and daily mindfulness were mediated by mindfulness. Another research carried out by Amutio et al. [ 37 ] attempted to estimate the effect of MBSR on mindfulness and relaxation states of 42 physicians. The primary aim of the study was to test the efficacy of MBSR in inducing relaxation among professionals from a highly distressing career background. Also, heart rate was included as a dependent variable in order to confirm that MBSR could act as a relaxation method at a physical level as well. Although relaxation is a byproduct of mindfulness, other possible positive outcomes that could have opened ways to enhance human well-being and flourishing, were not the object of focus in this study. In another study, de Vibe et al. [ 38 ] had reported a six-year-long longitudinal study, where the impact of a seven-week abridged MBSR is described. The study illustrates the well-being, coping, and mindfulness of 288 participants. Another popular psychotherapy that makes use of mindfulness is Acceptance and Commitment Therapy (ACT). A guided seven-week internet-delivered Acceptance and Commitment Therapy (iACT) was administered among 68 university students with high distress. The participants’ well-being (psychological, emotional, and social domains), life satisfaction, self-esteem, mindfulness, stress, anxiety, depression, psychological flexibility, and sense of coherence were assessed by eight psychological assessment tools [ 39 ]. Since the study had combined clinical and positive outcome measures and because the interaction among these variables was uncertain, it is safe to refrain from concluding that iACT would be useful as a positive psychology intervention. Mostly, the MBIs with psychotherapeutic properties are predominantly governed by deficit-reduction qualities and the positive outcomes are only consequential.

MBIs for children

Three of the reviewed studies had been conducted among children [ 32 , 40 , 41 ]. Eudaimonic well-being among children is an area in the scientific literature with extremely less empirical information [ 42 ]. And the operational definitions of eudaimonia assessed among children are found to be limited in scope. In a study that attempted to see the impact of an MBI among child population, Huppert & Johnson [ 41 ] had administered four 40 minutes of mindfulness classes, one session per week, to 155 boys belonging to the age group of fourteen and fifteen years. Pre and post-assessments were conducted on their mindfulness, resilience, well-being, and big-five personality variables. In another research, Flook et al. [ 32 ] had observed 68 preschool children who were administered with a 12-week Mindfulness-Based Kindness Curriculum. A randomized waitlist controlled design was employed to obtain the amount of their social competence (a combination of pro-social behavior and emotion regulation), sharing, delay of gratification, cognitive flexibility, inhibitory control, and academic performance. Devcich et al. [ 40 ] had carried out another study where a novel intervention namely “Pause, Breathe, Smile” was tested for its efficacy with an active-controlled pilot design, against an emotional literacy program. Duration for both of the programs was one-hour weekly sessions for eight weeks. The study assessed pre and post scores of 91 school children, on well-being—including hedonia and eudaimonia—and mindfulness. Considering that the target population is children, it is not to be expected to find a concept as complex as eudaimonia to be manipulated or measured effectively, particularly when the interventions do not follow a standardized procedure. Although mindfulness was taught, the studies did not primarily focus on the well-being or other positive functioning of the participants, possibly because of the difficulty in gathering information on positive experiences from children. Hence, the three different interventions adopted here cannot be considered as effective tools for enhancing well-being and flourishing, but they shall be useful tools for specific targeted behavioral modifications and academic performance.

Mindfulness apps

The use of online platforms for counselling and psychotherapy is becoming popular nowadays, especially since the outbreak of covid 19 pandemic in 2020 [ 43 , 44 ]. Not just the reduction of undesirable states of mind, but the enhancement of positive functioning is also getting wide acceptance at a global level [ 45 ]. There are a few commercial mindfulness-based applications accessible though smart phones that were also empirically validated through scientific researches. In this review of MBIs, two of the studies chosen had implemented two apps—“Calm” and “Headspace” to explore its impact on health and well-being. Bhayee et al. [ 46 ] had tested the therapeutic efficacy of a commercial neurofeedback assisted, technology-supported mindfulness training (NtsMT). The experimental group was exposed to the “Calm” app in a pre-planned manner with recorded instructions. They have used a randomized active-control trial among 26 participants. Electroencephalogram (EEG) was used as the neurofeedback mechanism, and the psychological variables assessed were attention and well-being. Champion et al. [ 47 ] had conducted another research using a self-guided mindfulness meditation app, “Headspace”. The introductory program of the Headspace, “Foundation 1 to 3” with 30 sessions (10 at each level), was administered to the participants. The minimum duration of a session was 10 min, and there was an option to increase the duration up to 15 and 20 min for second and third levels respectively. They have assessed the life satisfaction, stress, resilience, social impairment, depression, anxiety, hypochondriasis, and enjoyment and experience of 62 participants. Both of these studies had apparently anticipated reduced clinical symptoms from the interventions, and the range of positive outcomes assessed were too narrow, suggesting that the intended use of these apps, in the concerned studies, was not primarily positive functioning.

Positive relationships

Positive relationships is a component of eudaimonic well-being. Three studies selected for the review had utilized three different interventions with the principal aim of improving relationships. Carson et al. [ 48 ] had tested the effect of a novel intervention, Mindfulness-Based Relationship Enhancement (MBRE), on relationship satisfaction, relatedness, autonomy, interpersonal closeness, partner acceptance, relationship distress, spirituality, individual relaxation, and psychological distress. They had adopted a randomized waitlist controlled design and the participants were 44 relatively happy and non-distressed couples. Another MBI that aimed at improving ‘positive relationship’ was applied in a study by Coatsworth et al. [ 49 ]. They had tested the efficacy of the Mindfulness-Enhanced Strengthening Families Program (MSFP) against a standard of care condition and control groups. They have adopted a randomized controlled comparative effectiveness study design with 432 families. The intervention intended to impact interpersonal mindfulness in parenting, parent-youth relationship, youth behavior management, and parent well-being. MSFP was an adapted intervention meant to be a preventive measure to protect adolescents from substance use and behavior problems. With the added element of mindfulness in the adapted version of the intervention, some positive outcomes were also anticipated which were included as dependent variables. Kappen et al. [ 50 ] had conducted another study on positive relationship , using a brief 12-day online mindfulness program. Intended outcomes of this intervention were elevated relationship satisfaction, partner acceptance, and trait mindfulness. Adults who had been in a romantic relationship for at least one year were recruited through social networking sites. Despite being context-specific and not focusing on relationship enhancement in an exhaustive way, these interventions definitely throw some light on the status of MBIs that are considered to be relationship enhancers. Specifically, MBRE, MSFP, and the 12-day online mindfulness program are apparently effective to improve quality of relationships at specific contexts. Since these interventions are designed for healthier relationship between specific target populations, such as couples, the same interventions will not be sufficient to improve relationship quality in another situation.

Mindful self compassion (MSC)

MSC, an intervention developed by Neff and Germer [ 51 ], intends to build self compassion in both normal and clinical populations. It is fundamentally a mindfulness-based positive psychology intervention, which gives priority to self-compassion and secondary importance to mindfulness. Other outcomes resultant from compassion and mindfulness shall also be expected from MSC, but its focus is not shared with any further components of well-being or other positive psychology variables. The current review found two papers where three studies that employed MSC were reported. Neff & Germer [ 51 ] had performed a pilot study and another randomized waitlist controlled trial to examine the effect of the Mindful Self Compassion (MSC) program. The intervention was for eight weeks, one two-hour session per week. They have studied the impact of the intervention on self-compassion, mindfulness, connectedness, happiness, life satisfaction, depression, anxiety, and stress in the first study and have added two more dependent variables in the second study, which are avoidance, and compassion for others. In another study, Yela et al. [ 52 ] had explored the impact of a Mindful Self-Compassion (MSC) program on self-compassion, mindfulness, psychological well-being, anxiety, and depression among 61 psychology trainees. The intervention lasted for eight weeks, with a 2.5-hour session weekly. The MSC interventions applied in these three studies have acted as psychological tools to improve specific elements of eudaimonic and hedonic well-being, along with other factors. The positive impacts of the interventions were looked upon from the point of view of ‘improved well-being through improved mental health’ rather than enhancement of well-being, happiness, flourishing, or meaning in life. It is difficult to conclude whether MSC was effectively established as an MPI through the aforementioned studies, considering the nature of MPI as an intervention with primary focus on positive outcomes. Nevertheless, the study results indeed emphasize the positive potentials of MSC.

Loving kindness meditation (LKM)

LKM is a kind of Buddhist meditation that intends to induce “a feeling of warmth and caring for self and others” [ 53 ]. Among the 22 studies reviewed, two studies had incorporated interventions that utilized LKM. Fredrickson et al. [ 53 ], in their study, recruited 139 working adults into experimental and waitlist control groups and the former was administered with 13 measures that assessed 15 variables—mindfulness, agency thinking, pathway thinking, savoring beliefs, optimism, ego resilience, psychological well-being, dyadic adjustment, positive relations, illness symptoms, sleep quality, satisfaction with life, depression, differential emotions, and emotion experiences. LKM was provided to the former group that extended for seven weeks with one hour weekly sessions. In a different study, Sorensen et al. [ 54 ] had investigated the effects of a novel intervention called ‘Convergence’ that combined LKM and classic guitar music. The two active-controlled conditions were given either music alone or meditation alone. All three conditions were prolonged for three weeks, providing one session per week, and the participants were assessed for mindfulness, self-compassion, fears of compassion, stress and anxiety, and mental well-being. Both of these researches focused less on the positive qualities of the intervention. LKM is a meditation practice that involves mindfulness elements but with an additional intentional focus on warm and tender feelings toward oneself and the others. LKM strives to instill an attitude of loving-kindness and do not attempts to enhance any other psychological properties directly. But the study results indicate that it is sufficient to improve specific aspects of hedonic and eudaimonic well-being.

MBIs that may act as MPIs

Positive psychology is relatively young and the number of studies is not yet comparable with that of clinical psychology and other deficit-focused fields of psychology. But it is a rapidly developing area that overlaps with the studies on mindfulness. There were three researches in this review where the positive psychological variables were looked into more vigorously. One of these was reported by Rodríguez-Carvajal et al. [ 55 ] where a non-randomized controlled study was used among 73 participants to substantiate the effect of a three-week Mindfulness Integrative Model (MIM) on mindfulness, self-compassion, and positive states of mind. In another instance, Pogrebtsova et al. [ 56 ] had studied the impact of a five-day combined mindful-reappraisal intervention on students’ positive and negative experiences, positive re-appraisal, decentering, curiosity, and optimism. The sample consisted of 106 participants where 36 were in the experimental group, which was compared against a ‘standard of care’ condition and active control group. The third study was carried out by Vich et al. [ 57 ] where a modified intervention, ‘Relational Mindfulness Training’ (RMT) was administered to 75 management students, and their self-compassion, compassion, stress, mindfulness, and happiness were measured. Despite a larger part of well-being aspects being still unexplored, the positive potentials of MBIs are well-documented in these researches. Further studies shall unravel the actual positive qualities of these interventions.

Mindfulness-based positive psychology interventions (MPIs)

It sounds as if two studies had explored the exponential positive power of MBIs. Ivtzan et al. [ 58 ] had studied the impact of a novel MPI, eight-week online ‘Positive Mindfulness Program’ (PMP) on eudaimonic and hedonic well-being, stress, depression, mindfulness, gratitude, self-compassion, autonomy component of psychological well-being scale, self-efficacy, meaning in life, compassion for others, and appreciation for the present moment, among 168 adults from 20 different countries. They have used a randomized waitlist controlled trial with pre, post, and one-month follow up data. Here, PMP had tested both clinical and positive outcomes, but basically it is an intervention developed to improve well-being through nine specific components –(i) positive emotions, (ii) self-compassion, (iii) well-being (happiness), (iv) autonomy, (v) mindfulness, (vi) self-efficacy (strengths), (vii) meaning, (viii) compassion, and (ix) engagement (savoring)’ [ 1 ]. In a different study by Smith et al. [ 59 ], 31 meditating adults were assessed for quality of life, subjective well-being, well-being, valuing, psychological flexibility, mindfulness, and cognitive fusion. The experimental group consisted of 17 individuals who had practiced Dharma in Daily Life (DIDL) for 30 minutes per day, extending six days a week, for two years course period and six months follow-up period, and possibly beyond. DIDL indeed had undeniable positive impact, but the intensity and duration raises questions about its feasibility as a common MPI. Nevertheless, both PMP and DIDL show promising utility of MPIs for enhancement of eudaimonia, hedonia, and other specific positive variables.

Outcomes of MBIs

The reviewed studies vary greatly based on research designs, outcome measures, intensity and structure of interventions, and analytical methods adopted. Hence, due to this high heterogeneity, it was only possible to narrate a peripheral report of outcomes. Depending on the effect sizes of outcome measures, there is an extended scope for further studies which surpass the objectives of the current review. Here, based on the intended positive outcomes of the interventions, studies are categorized into: (1) Enhancement of eudaimonia, (2) Enhancement of hedonia, and (3) Enhancement of other positive variables.

Enhancement of eudaimonia

In a randomized controlled efficacy trial, Rasanen et al. [ 39 ] found that there is a significant increase in well-being, life satisfaction, and mindfulness among the participants who had exposed to the iACT. They had also reported less stress and depression. These effects were intact in a 12-month follow-up as well. The study results show the plausible impact of an MBI on well-being, life satisfaction, and mindfulness, that shall contribute to a sense of purposeful living, one of the different components of eudaimonia.

Devcich et al. [ 40 ] had administered a mindfulness-based intervention, ‘Pause, Breathe, Smile’, to 45 school children as part of a research. Compared to an active control group, the former children had shown higher mindfulness and well-being (hedonia, eudaimonia, and socially desirable responsibility). The MBI ‘Pause, Breathe, Smile’ is likely to contribute to the eudaimonic well-being of children, not in a comprehensive way but to a limited extent.

Carson et al. [ 48 ] had observed the significant positive impact of Mindfulness-Based Relationship Enhancement on relationship functioning and well-being of couples, even when the couples were relatively happy and non-distressed at the baseline level. They had received results that supported the beneficial effect of the MBI on all dependent variables that was maintained at a three-month follow-up. In their study, Coatsworth et al. [ 49 ] had applied MSFP for strengthening four conditions related to family functioning. They have concluded that MSFP improved interpersonal mindfulness in parenting, parent-youth relationships, youth behavior management, and parent well-being. Kappen et al. [ 50 ] reported that, after a 12-day online mindfulness practice, 56 participants with lower baseline mindfulness reported higher relationship satisfaction and partner acceptance compared to the control group. Otherwise, both the groups, regardless of the administration of mindfulness practice or psycho-education, showed no significant difference in the aforementioned variables. In these studies, three different interventions indicate the possible usage of MBIs for ‘positive relationships’, a component of eudaimonic well-being.

Yela et al. [ 52 ] had studied the effects of MSC program and found that it has a significant impact on self-compassion, mindfulness, and psychological well-being (PWB) or eudaimonia. Despite focusing on the enhancement of compassion alone, the intervention proved to be a potential MPI for eudaimonic enhancement.

Ivtzan et al. [ 58 ] had tested the impact of PMP, on 11 psychological variables. The result indicated that there was a significant difference between the experimental and control groups on the basis of their scores of all the 11 dependent variables, including eudaimonic and hedonic well-being, mindfulness, meaning in life, compassion, and gratitude. PMP focuses on enhancement of both hedonic and eudaimonic well-being and accounts promising outcomes as an MPI for eudaimonic enhancement.

Enhancement of hedonia

In a field experimental study, Fredrickson et al. [ 53 ] found that the practice of LKM improved participants’ positive emotions (amusement, awe, contentment, joy, gratitude, hope, interest, love, and pride, collectively), and its effect expanded beyond the duration of meditation and cumulated overtime. Pogrebtsova et al. [ 56 ] had administered a five-day mindful reappraisal intervention to 36 participants and acquired results that suggest a decrease in negative affect and increase in positive affect toward the end of the intervention, compared to the scores of an active control and a standard of care conditions. Smith et al. [ 59 ] elucidated an instance when 17 participants were studied against a control group of 14 after getting exposed to DIDL intervention. It was stated that the experimental group, post-intervention, reported higher subjective well-being, well-being, mindfulness, psychological flexibility, and valuing. Nyklicek & Kuijpers [ 28 ] had narrated the impact of MBSR on stress, vital exhaustion, positive affect, quality of life, and mindfulness, in a randomized controlled trial. Compared to the control group, individuals exposed to the MBSR reported decreased stress and vital exhaustion, and increased positive affect, quality of life, and mindfulness. In a study using MIM, Rodriguez-Carvajal et al. [ 55 ] had found that the intervention enhanced mindfulness, self-compassion, and positive mental states.

The interventions mentioned above are valuable in improving specific aspects of hedonic well-being—either by reducing negative experiences or by improving pleasure and joy.

Enhancement of other positive variables

Flook et al. [ 32 ] had obtained evidence for a 12-week mindfulness-based Kindness Curriculum being effective in improving social competence, including pro-social behavior and emotion regulation, of pre-school children. It had also improved academic performance, tendency to delay gratification, and cognitive flexibility. In a longitudinal study, de Vibe et al. [ 38 ] reported that after a six-year follow-up, the participants who had undergone a 7-week abridged MBSR scored higher in well-being, mindfulness, and problem-focused coping that was a predictor of higher well-being. They had also revealed deteriorated avoidance-focused coping. The results were present even among the participants with low adherence to the regular practice of MBSR. Amutio et al. [ 37 ] have also described the effect of MBSR on well-being and related variables. At the end of the intervention period, participants in the experimental group scored significantly higher in mindfulness and relaxation. After a 10-month maintenance phase, their already reported positive outcomes were found to have increased even higher, particularly the scores on mindfulness, and all four dimensions of relaxation state—mindfulness, positive energy, transcendence, and relaxation. Bhayee et al. [ 46 ], using the app 'Calm', had studied the impact of an NtsMT on attention and well-being. The result suggested a moderate effect of mindfulness on attention and well-being while previous literature had a different say on its effect size. The reason shall be attributed to the delivery mode of the intervention, its duration, or both. Sorensen et al. [ 54 ] had introduced a novel intervention, Convergence , that was tested for its efficacy in comparison with an LKM-only group and a music-only group. The results indicated that all these three conditions improved mindfulness, self compassion, and well-being with small effect sizes. A study conducted by Huppert & Johnson [ 41 ] revealed high positive association between the time spent for mindfulness practice outside the intervention period and the amount of mindfulness and well-being. Other than that, between control and experimental groups, no significant differences were observed. The effect of RMT on compassion, stress, and mindfulness were assessed by Vich et al. [ 57 ]. Their study results outlined that RMT has a significant impact on self-compassion, stress, and mindfulness in the long run. RMT had an impact on compassion, and subjective happiness for a short time, but failed to sustain it over time. In a pilot randomized controlled trial, Champion et al. [ 47 ] had received the effect of the use of a mindfulness meditation app ‘Headspace’ on life satisfaction, stress, and resilience. Highest improvement was on 10 th session, that dropped moderately by the last and 30th session. Through two subsequent studies, Neff & Germer [ 51 ] obtained evidences for the impact of MSC on enhanced mindfulness, self-compassion and well-being.

MBIs as mindfulness-based positive psychology interventions (MPIs)

In the current systematic review, 21 papers were reviewed that described 22 studies on the impact of MBIs over positive human functioning, with prime importance given to eudaimonic well-being and secondary preference given to hedonic and other positive psychology variables. The latter was given secondary focus as hedonic well-being or the tendency to seek pleasure and avoid pain is mostly associated with clinical symptom reduction and temporary pleasurable experiences, rather than well-being and flourishing. Most of the MBIs reviewed were developed for specific needs not comprehensively focusing on either eudaimonia or hedonia and other positive psychology variables. Interventions administered among children were reported by three studies [ 32 , 40 , 41 ] and all these three have focused on a few specific positive psychology variables which cannot be attributed to an overall enhancement in eudaimonic or hedonic well-being. Three studies [ 48 , 49 , 50 ] have focused on a dimension of eudaimonic well-being—positive relationships. One of these is an adapted preventive intervention for adolescent substance use and problem behavior, and could not be considered as an MPI. The target population for six studies was college/university students [ 38 , 39 , 47 , 52 , 56 , 57 ]. One of these has chosen only distressed students and none of the studies focused entirely on well-being. Ten studies had recruited the general adult population through online or regular modes. Some studies advertised for volunteers as participants and some have recruited participants from institutions under different conditions. Most of the studies offered remunerations at various points. None of these studies employed interventions for enhancement of well-being with prime importance, and the positive impact of all of these MBIs was limited, focusing on specific aspects like self-compassion, mindfulness, or resilience. Hence, without ignoring the positive potential of these MBIs, it is required to point out the need for exploring positive outcomes of MBIs more extensively, and modify the existing interventions if required, to incorporate facilities to enhance positive outcomes.

Limitations

The review was restricted to three databases and manual search, and the possibility of unintentional exclusion of relevant articles indexed in other databases cannot be ignored. It is also possible that some of the excluded articles that primarily focus on clinical variables had reported the positive potentials of those clinical interventions. Though not high, there is a risk of bias in the cumulative result. And high heterogeneity of reviewed studies restricted the current research to opt for a systematic review rather than meta-analysis.

Conclusions

The current review has identified the major studies where MBIs were applied and its impact on positive human functioning assessed. The nature, pattern, duration, and focal area of interventions varied greatly and mostly centered around a few specific positive variables rather than overall well-being and flourishing. Application of MBIs for hedonic and other positive variables is found to be more frequent than the usage of MBIs for eudaimonic enhancement. This was not concluded from just the review of the final 21 articles, but from the entire process of finalizing those studies. This is consistent with the statement of Deci & Ryan [ 60 ] who had noted that the number of studies on hedonia greatly exceeds than that on eudaimonia. Hedonic well-being was closely associated with clinical symptom reduction instead of increment in the experience of perceived pleasure. Most of the MBIs applied with expected positive outcomes were context-specific or limited in the scope of applicability. The review was futile in finding any singularly positive-psychology oriented interventions, but a few of the interventions show powerful utility as an MBI that could enhance specific positive variables. Further empirical explorations shall reveal the potency of these MBIs as mindfulness-based positive psychology interventions. Modifications in the structure and functions to be more inclusive of contexts and populations would yield better positive outcomes of the existing MBIs. Also, MBIs that aimed at catering the needs of the recipients based on factors such as culture, ethnicity, and gender would result in highly effective MPIs. From the review, it could also be concluded that it is imperative to develop interventions with sole focus on enhancement of positive potentials, especially eudaimonic enhancement.

Study results point out that physical pleasures derived out of hedonia are not sufficient for the experience of well-being [ 61 , 62 , 63 ]. Keyes & Annas [ 64 ] pointed out the gulf between individuals with high hedonic well-being (48.5%) and their flourishing (18%). This explains the severe eudaimonic deficiency that contributes to the lack of flourishing. And in some other personal or social situations where hedonia can contribute little to a person’s well-being—such as chronic illnesses, physical or psychological pain, financial insecurity, childlessness, bereavement, or social/political unrest—eudaimonia is inevitable to maintain general well-being, happiness, contentment, and a sense of meaning and purpose in life. Eudaimonia apparently buffers against possible psychological harm also [ 64 ]. Hence it demands explorations in the direction of eudaimonic enhancement across different populations, cultures, and contexts. Unfortunately, few researches have addressed this issue so far and eudaimonic enhancement still remains a neglected area within applied positive psychology. Considering the paucity of MPIs exclusively for eudaimonic enhancement, it is recommended that immediate further actions are essential to develop, validate, and avail the same, among both clinical and non-clinical populations. In conclusion, the current study has reviewed the major studies where the MBIs are used for enhancement of eudaimonia, hedonia, and other positive psychology variables. It contributes to the existing scientific literature by pointing out the positive potentials of MBIs and the endless possibilities of empirical studies on the application of MPIs. Finally, the review emphasizes the need of future studies paying attention to the utilization of eudaimonic enhancement potential of MPIs along with the focus on enhancement of hedonic and other positive outcomes.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Mindfulness-Based Intervention

Positive Psychology Intervention

Mindfulness-Based Positive Psychology Intervention

Mindfulness Based Stress Reduction

Internet-delivered Acceptance and Commitment Therapy

Neurofeedback assisted technology supported mindfulness training

Electroencephalogram

Mindfulness-Based Relationship Enhancement

Mindfulness-Enhanced Strengthening Families Program

Mindful Self Compassion

Loving Kindness Meditation

Mindfulness Integrative Model

Relational Mindfulness Training

Positive Mindfulness Program

Dharma in Daily Life

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Positive psychology interventions: a meta-analysis of randomized controlled studies

• Linda Bolier 1 ,
• Merel Haverman 2 ,
• Gerben J Westerhof 3 ,
• Heleen Riper 4 , 5 ,
• Filip Smit 1 , 6 &
• Ernst Bohlmeijer 3  

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The use of positive psychological interventions may be considered as a complementary strategy in mental health promotion and treatment. The present article constitutes a meta-analytical study of the effectiveness of positive psychology interventions for the general public and for individuals with specific psychosocial problems.

We conducted a systematic literature search using PubMed, PsychInfo, the Cochrane register, and manual searches. Forty articles, describing 39 studies, totaling 6,139 participants, met the criteria for inclusion. The outcome measures used were subjective well-being, psychological well-being and depression. Positive psychology interventions included self-help interventions, group training and individual therapy.

The standardized mean difference was 0.34 for subjective well-being, 0.20 for psychological well-being and 0.23 for depression indicating small effects for positive psychology interventions. At follow-up from three to six months, effect sizes are small, but still significant for subjective well-being and psychological well-being, indicating that effects are fairly sustainable. Heterogeneity was rather high, due to the wide diversity of the studies included. Several variables moderated the impact on depression: Interventions were more effective if they were of longer duration, if recruitment was conducted via referral or hospital, if interventions were delivered to people with certain psychosocial problems and on an individual basis, and if the study design was of low quality. Moreover, indications for publication bias were found, and the quality of the studies varied considerably.

Conclusions

The results of this meta-analysis show that positive psychology interventions can be effective in the enhancement of subjective well-being and psychological well-being, as well as in helping to reduce depressive symptoms. Additional high-quality peer-reviewed studies in diverse (clinical) populations are needed to strengthen the evidence-base for positive psychology interventions.

Peer Review reports

Over the past few decades, many psychological treatments have been developed for common mental problems and disorders such as depression and anxiety. Effectiveness has been established for cognitive behavioral therapy [ 1 , 2 ], problem-solving therapy [ 3 ] and interpersonal therapy [ 4 ]. Preventive and early interventions, such as the Coping with Depression course [ 5 ], the Don’t Panic course [ 6 ] and Living Life to the Full [ 7 , 8 ] are also available. The existing evidence shows that the mental health care system has traditionally focused more on treatment of mental disorders than on prevention. However, it is recognized that mental health is more than just the absence of mental illness, as expressed in the World Health Organization’s definition of mental health:

Mental health is a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively, and is able to make a contribution to his or her community [ 9 ].

Under this definition well-being and positive functioning are core elements of mental health. It underscores that people can be free of mental illness and at the same time be unhappy and exhibit a high level of dysfunction in daily life [ 10 ]. Likewise, people with mental disorders, can be happy by coping well with their illness and enjoy a satisfactory quality of life [ 11 ]. Subjective well-being refers to a cognitive and/or affective appraisal of one’s own life as a whole [ 12 ]. Psychological well-being focuses on the optimal functioning of the individual and includes concepts such as mastery, hope and purpose in life [ 13 , 14 ]. The benefits of well-being are recorded both in cross-sectional and longitudinal research and include improved productivity at work, having more meaningful relationships and less health care uptake [ 15 , 16 ]. Well-being is also positively associated with better physical health [ 17 – 19 ]. It is possible that this association is mediated by a healthy lifestyle and a healthier immune system, which buffers the adverse influence of stress [ 20 ]. In addition, the available evidence suggests that well-being reduces the risk of developing mental symptoms and disorders [ 21 , 22 ] and helps reduce mortality risks in people with physical disease [ 23 ].

Seligman and Csikszentmihaly’s (2000) pioneered these principles of positive psychology in their well-known article entitled ‘Positive psychology: An introduction’, published in a special issue of the American Psychologist. They argued that a negative bias prevailed in psychology research, where the main focus was on negative emotions and treating mental health problems and disorders [ 24 ]. Although the basic concepts of well-being, happiness and human flourishing have been studied for some decades [ 12 , 25 – 27 ], there was a lack of evidence-based interventions [ 24 ]. Since the publication of Seligman and Csikszentmihaly’s seminal article, the positive psychology movement has grown rapidly. The ever-expanding International Positive Psychology Association is among the most extensive research networks in the world [ 28 ] and many clinicians and coaches embrace the body of thought that positive psychology has to offer.

Consequently, the number of evaluation studies has greatly increased over the past decade. Many of these studies demonstrated the efficacy of positive psychology interventions such as counting your blessings [ 29 , 30 ], practicing kindness [ 31 ], setting personal goals [ 32 , 33 ], expressing gratitude [ 30 , 34 ] and using personal strengths [ 30 ] to enhance well-being, and, in some cases, to alleviate depressive symptoms [ 30 ]. Many of these interventions are delivered in a self-help format. Sin and Lyubomirsky (2009) conducted a meta-analytical review of the evidence for the effectiveness of positive psychology interventions (PPIs). Their results show that PPIs can indeed be effective in enhancing well-being (r = 0.29, standardized mean difference Cohen’s d = 0.61) and help to reduce depressive symptom levels in clinical populations (r = 0.31, Cohen’s d = 0.65). However, this meta-analysis had some important limitations. First, the meta-analysis included both randomized studies and quasi-experimental studies. Second, study quality was not addressed as a potential effect moderator. In recent meta-analyses, it has been shown that the treatment effects of psychotherapy have been overestimated in lower quality studies [ 35 , 36 ]. The lack of clarity in the inclusion criteria constitutes a third limitation. Intervention studies, although related to positive psychology but not strictly developed within this new framework (e.g. mindfulness, life-review) were included in the meta-analysis. However, inclusion of these studies reduces the robustness of the results for pure positive psychology interventions.

Present study

The aim of the present study is to conduct a meta-analysis of the effects of specific positive psychology interventions in the general public and in people with specific psychosocial problems. Subjective well-being, psychological well-being and depressive symptoms were the outcome measures. Potential variables moderating the effectiveness of the interventions, such as intervention type, duration and quality of the research design, were also examined. This study will add to the existing literature and the above meta-analytical review [ 37 ] by 1) only including randomized controlled studies, 2) taking the methodological quality of the primary studies into account, 3) including the most recent studies (2009 – 2012), 4) analyzing not only post-test effects but also long-term effects at follow up, and 5) applying clear inclusion criteria for the type of interventions and study design.

Search strategy

A systematic literature search was carried out in PsychInfo, PubMed and the Cochrane Central Register of Controlled Trials, covering the period from 1998 (the start of the positive psychology movement) to November 2012. The search strategy was based on two key components: there should be a) a specific positive psychology intervention, and b) an outcome evaluation. The following MeSH terms and text words were used: “well-being” or “happiness” or “happy*”, “optimism”, “positive psychology” in combination with “intervention”, “treatment”, “therapy” and “prevention”. This was combined with terms related to outcome research: “effect*”, or “effic*”, or “outcome*”, or “evaluat*”. We also cross-checked the references from the studies retrieved, the earlier meta-analysis of Sin & Lyubomirsky (2009) and two other reviews of positive psychological interventions [ 38 , 39 ]. The search was restricted to peer-reviewed studies in the English language.

Selection of studies

Two reviewers (LB and MH) independently selected potentially eligible studies in two phases. At the first phase, selection was based on title and abstract, and at the second phase on the full-text article. All studies identified as potentially eligible by at least one of the reviewers during the first selection phase, were re-assessed at the second selection phase. During the second phase, disagreements between the reviewers were resolved by consensus. The inter-rater reliability (kappa) was 0.90.

The inclusion criteria were as follows:

Examination of the effects of a positive psychology intervention. A positive psychology intervention (PPI) was defined in accordance with Sin and Lyubomirsky’s (2009) article as a psychological intervention (training, exercise, therapy) primarily aimed at raising positive feelings, positive cognitions or positive behavior as opposed to interventions aiming to reduce symptoms, problems or disorders. The intervention should have been explicitly developed in line with the theoretical tradition of positive psychology (usually reported in the introduction section of an article).

Randomization of the study subjects (randomizing individuals, not groups) and the presence of a comparator condition (no intervention, placebo, care as usual).

Publication in a peer-reviewed journal.

At least one of the following are measured as outcomes: well-being (subjective well-being and/or psychological well-being) or depression (diagnosis or symptoms).

Sufficient statistics are reported to enable the calculation of standardized effect sizes.

If necessary, authors were contacted for supplementary data. We excluded studies that involved physical exercises aimed at the improvement of well-being, as well as mindfulness or meditation interventions, forgiveness therapy, life-review and reminiscence interventions. Furthermore, well-being interventions in diseased populations not explicitly grounded in positive psychology theory (‘coping with disease courses’) were excluded. Apart from being beyond the scope of this meta-analysis, extensive meta-analyses have already been published for these types of intervention [ 40 – 42 ]. This does not imply that these interventions do not have positive effects on well-being, a point which will be elaborated on in the discussion section of this paper.

Data extraction

Data extraction and study quality assessment were performed by one reviewer (LB) and independently checked by a second reviewer (MH). Disagreements were resolved by consensus. Data were collected on design, intervention characteristics, target group, recruitment methods, delivery mode, number of sessions, attrition rates, control group, outcome measures and effect sizes (post-test and at follow up of at least 3 months). The primary outcomes in our meta-analysis were subjective well-being (SWB), psychological well-being (PWB) and depressive symptoms/depression.

The methodological quality of the included studies was assessed using a short scale of six criteria tailored to those studies and based on criteria established by the Cochrane collaboration [ 43 ]: 1) Adequacy of randomization concealment, 2) Blinding of subjects to the condition (blinding of assessors was not applicable in most cases), 3) Baseline comparability: were study groups comparable at the beginning of the study and was this explicitly assessed? (Or were adjustments made to correct for baseline imbalance using appropriate covariates), 4) Power analysis: is there an adequate power analysis and/or are there at least 50 participants in the analysis?, 5) Completeness of follow up data: clear attrition analysis and loss to follow up < 50%, 6) Handling of missing data: the use of intention-to-treat analysis (as opposed to a completers-only analysis). Each criterion was rated as 0 (study does not meet criterion) or 1 (study meets criterion). The inter-rater reliability (kappa) was 0.91. The quality of a study was assessed as high when five or six criteria were met, medium when three or four criteria were met, and low when zero, one or two criteria were met. Along with a summary score, the aspects relating to quality were also considered individually, as results based on composite quality scales can be equivocal [ 44 ]. Table  1 shows the quality assessment for each study. The quality of the studies was scored from 1 to 5 (M = 2.56; SD = 1.25). Twenty studies were rated as low, 18 were of medium quality and one study was of high quality. None of the studies met all quality criteria. The average number of participants in the analysis was rather high (17 out of 39 studies scored positive on this criterion), although none of the studies reported an adequate power analysis. Also, baseline comparability was frequently reported (26/39 studies). On the other hand, independence in the randomization procedure was seldom reported (7/39 studies) and an intention-to-treat analysis was rarely conducted (3/39 studies).

• Meta-analysis

In a meta-analysis, the effects found in the primary studies are converted into a standardized effect size, which is no longer placed on the original measurement scale, and can therefore be compared with measures from other scales. For each study, we calculated effect sizes (Cohen’s d ) by subtracting the average score of the experimental group (Me) from the average score of the control group (Mc), and dividing the result by the pooled standard deviations of both groups. This was done at post-test because randomization usually results in comparable groups across conditions at baseline. However, if baseline differences on outcome variables did exist despite the randomization, d’s were calculated on the basis of pre- post-test differences: by calculating the standardized pre- post change score for the experimental group (de) and the control group (dc) and subsequently calculating their difference as Δd= de – dc. For example, an effect size of 0.5 indicates that the mean of the experimental group is half a standard unit (standard deviation) larger than the mean of the control group. From a clinical perspective, effect sizes of 0.56 – 1.2 can be interpreted as large, while effect sizes of 0.33 – 0.55 are of medium size, and effects of 0 – 0.32 are small [ 45 ].

In the calculation of effect sizes for depression, we used instruments that explicitly measure depression (e.g. the Beck Depression Inventory, or the Center for Epidemiological Studies Depression Scale). For subjective and psychological well-being, we also used instruments related to the construct of well-being (such as positive affect for SWB and hope for PWB). If more than one measure was used for SWB, PWB or depression, the mean of the effect sizes was calculated, so that each study outcome had one effect size. If more than one experimental group was compared with a control condition in a particular study, the number of subjects in the control groups was evenly divided across the experimental groups so that each subject was used only once in the meta-analysis.

To calculate pooled mean effect sizes, we used Comprehensive Meta-Analysis (CMA, Version 2.2.064). Due to the diversity of studies and populations, a common effect size was not assumed and we expected considerable heterogeneity. Therefore, it was decided a priori to use the ‘random effects model’. Effect sizes may differ under this model, not only because of random error within studies (as in the fixed effects model), but also as a result of true variation in effect sizes between studies. The outcomes of the random effects model are conservative in that their 95% Confidence Intervals (CIs) are often broad, thus reducing the likelihood of type-II errors.

We tested for the presence of heterogeneity with two indicators. First, we calculated the Q-statistic. A significant Q rejects the null-hypothesis of homogeneity and indicates that the true effect size probably does vary from study to study. Second, the I 2 -statistic was calculated. This is a percentage indicating the study-to-study dispersion due to real differences, over and above random sampling error. A value of 0% indicates an absence of dispersion, and larger values show increasing levels of heterogeneity where 25% can be considered as low, 50% as moderate and 75% as a high level of heterogeneity [ 46 ].

Owing to the expected high level of heterogeneity, all studies were taken into account. Outliers were considered, but not automatically removed from the meta-analysis. The procedure of removing outliers which are outside the confidence interval of the pooled effect size is advised when a common effect size is assumed. However, in our meta-analysis, high dispersion was expected and therefore only the exclusion of Cohen’s d > 2.5 from the final sample was planned.

Subgroup analyses were performed by testing differences in Cohen’s d’s between subgroups. Six potential moderators were determined based on previous research and the characteristics of the investigated interventions and studies: 1) Self-selected sample/not self-selected: did the participants know that the aim of the intervention was to make them feel better?; 2) Duration: less than four weeks, four to eight weeks, or more than eight weeks; 3) Type of intervention: self-help, group intervention, or individual therapy; 4) Recruitment method: community (in a community center, local newspapers), internet, by referral/hospital, at university; 5) Psychosocial problems (Yes/none): was the data based on a group with certain psychosocial problems or was the study open to everyone?; 6) Quality rating: low (score 1 or 2), medium (score 3 or 4) or high (score 5 or 6). The impact of the duration and quality ratings was also assessed using meta-regression.

Results of meta-analysis may be biased due to the fact that studies with non-significant or negative results are less likely to be published in peer-reviewed journals [ 47 ]. In order to address this issue, we used three indices: funnel plots, the Orwin’s fail-safe number and the Trim and Fill method. A funnel plot is a graph of effect size against study size. When publication bias is absent, the observed studies are expected to be distributed symmetrically around the pooled effect size. The Orwin’s fail-safe number indicates the number of non-significant unpublished studies needed to reduce the overall significant effect to non-significance (according to a self-stated criterium) [ 48 ]. The effect size can be considered to be robust if the number of studies required to reduce the overall effect size to a non-significant level exceeds 5 K + 10, where K is the number of studies included. If asymmetry is found in the funnel plot, the Trim and Fill method adjusts the pooled effect size for the outcomes of missing studies [ 49 ]. Imputing missing studies restores the symmetry in the funnel plot and an adjusted effect size can be calculated.

For the reporting of the results of this meta-analysis, we applied Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 50 ].

Description of studies

The selection process is illustrated in Figure  1 . First, 5,335 titles were retrieved from databases and 55 titles were identified through searching the reference list accompanying the meta-analysis by Sin and Lyubomirsky (2009) [ 37 ] as well as two other literature reviews of positive psychological interventions [ 38 , 39 ]. After reviewing the titles and abstracts and removing duplicates, 84 articles were identified as being potentially eligible for inclusion in our study. Of these 84 articles, 40 articles in which 39 studies were described, met our inclusion criteria (of these, 17 articles describing 19 studies were also included in the meta-analysis by Sin and Lyubomirsky, 2009). In two articles [ 29 , 51 ] two studies were described, and one study [ 52 – 55 ] was published in four articles.

Flow diagram.

The characteristics of the studies included are described in Table  2 . The studies evaluated 6,139 subjects, 4,043 in PPI groups and 2,096 in control groups. Ten studies compared a PPI with a no-intervention control group [ 29 , 51 , 56 – 63 ], 17 studies compared a PPI with a placebo intervention [ 29 , 30 , 32 , 34 , 52 – 55 , 64 – 75 ], seven studies with a waiting list control group [ 33 , 76 – 81 ] and five studies with another active intervention (care as usual) [ 51 , 82 – 85 ]. A minority of seven studies [ 51 , 57 , 76 , 77 , 82 , 83 ] applied inclusion criteria to target a specific group with psychosocial problems such as depression and anxiety symptoms. Half of the studies, 19 in total, recruited the subjects (not necessarily students) through university [ 29 , 32 , 34 , 51 , 56 , 58 – 61 , 64 – 68 , 70 , 72 , 75 , 80 , 85 ]. In seven studies subjects were recruited in the community [ 33 , 57 , 71 , 73 , 76 , 77 , 81 ], in four studies by referral from a practitioner or hospital [ 29 , 51 , 82 , 83 ], in three studies in an organization [ 62 , 78 , 79 ] and six studies recruited through the internet [ 30 , 52 – 55 , 63 , 69 , 74 , 84 ]. Twenty-eight studies measured subjective well-being, 20 studied psychological well-being and 14 studied depressive symptoms. Half of the studies (20) were aimed at adult populations [ 29 , 30 , 33 , 51 – 56 , 62 , 63 , 65 , 69 , 71 , 73 , 74 , 76 , 78 , 79 , 81 – 84 ]. A substantial number of studies (17) were aimed at college students [ 29 , 32 , 34 , 51 , 58 – 61 , 64 , 66 – 68 , 70 , 72 , 75 , 80 , 85 ] and two studies were aimed at older subjects [ 57 , 77 ]. In most studies (26) the PPI was delivered in the form of self-help [ 29 , 30 , 34 , 52 – 56 , 58 , 59 , 61 , 63 – 71 , 73 – 75 , 77 , 78 , 80 , 84 , 85 ]. Eight studies used group PPIs [ 32 , 33 , 51 , 57 , 60 , 62 , 72 , 76 ] and five used individual PPIs [ 51 , 79 , 81 – 83 ]. Intensity varied considerably across studies, ranging from a short one-day exercise [ 70 ] and a two-week self-help intervention [ 65 ] to intensive therapy [ 51 , 82 , 83 ] and coaching [ 33 , 81 ].

Post-test effects

The random effect model showed that the PPIs were effective for all three outcomes. Results are presented in Table  3 . The effect sizes of the individual studies at post-test are plotted in Figures  2 , 3 and 4 .

Post-test effects of positive psychology interventions on subjective well-being. The square boxes show effect size and sample size (the larger the box, the larger the sample size) in each study, and the line the 95% confidence interval. The diamond reflects the pooled effect size and the width of the 95% confidence interval.

Post-test effects of positive psychology interventions on psychological well-being. The square boxes show effect size and sample size (the larger the box, the larger the sample size) in each study, and the line the 95% confidence interval. The diamond reflects the pooled effect size and the width of the 95% confidence interval.

Post-test effects of positive psychology interventions on depressive symptoms. The square boxes show effect size and sample size (the larger the box, the larger the sample size) in each study, and the line the 95% confidence interval. The diamond reflects the pooled effect size and the width of the 95% confidence interval.

A composite moderate and statistically significant effect size (Cohen’s d ) was observed for subjective well-being d = 0.34 (95% CI [0.22, 0.45], p<.01). For psychological well-being, Cohen’s d was 0.20 (95% CI [0.09, 0.30], p<.01) and for depression d = 0.23 (95% CI [0.09, 0.38], p<.01), which can be considered as small.

Heterogeneity was moderate for subjective well-being (I 2 = 49.5%) and depression (I 2 = 47.0%), and low for psychological well-being (I 2 = 29.0%). Effect sizes ranged from −0.09 [ 66 ] to 1.30 [ 64 ] for subjective well-being, -0.06 [ 78 ] to 2.4 [ 83 ] for psychological well-being and −0.17 [ 69 ] to 1.75 [ 83 ] for depression.

Removing outliers reduced effect sizes for all three outcomes: 0.26 (95% CI [0.18, 0.33], Z=6.43, p<.01) for subjective well-being (Burton & King, 2004 and Peters et al., 2010 removed) [ 64 , 70 ], 0.17 (95% CI [0.09, 0.25], Z=4.18, p<.01) for psychological well-being (Fava et al. (2005) removed) [ 83 ] and 0.18 (95% CI [0.07, 0.28], Z=3.33, p<.01) for depression (Fava, 2005 and Seligman, 2006 study 2, removed) [ 51 , 83 ]. Removing the outliers reduced heterogeneity substantially (to a non-significant level).

Follow-up effects

Ten studies examined follow-up effects after at least three months and up to 12 months (Table  3 ). For the purposes of interpretation, we used only those studies examining effects from three to six months (short-term follow-up), thus excluding Fava et al. (2005) [ 83 ] which had a follow-up at one year. The random-effects model demonstrated small but significant effects in comparison with the control groups for subjective well-being (Cohen’s d 0.22, 95% CI [0.05, 0.38], p<.01) and for psychological well-being (0.16, 95% CI [0.02, 0.30], p = .03). The effect was not significant for depression (0.17, 95% CI [−0.06, 0.39], p = .15). Heterogeneity was low for subjective well-being (I 2 = 1.1%) and psychological well-being (I 2 = 26.0%), and high for depression (I 2 = 63.9%).

Subgroup analyses

Subgroup analyses are presented in Table  4 . We looked at self-selection, duration of the intervention, type of intervention, recruitment method, application of inclusion criteria related to certain psychosocial problems, and quality rating.

For depression, five out of six subgroups of studies resulted in significantly higher effect sizes. Higher effect sizes were found for 1) interventions of a longer duration (only in the meta regression analysis), 2) individual interventions, 3) studies involving referral from a health care practitioner or hospital, 4) studies which applied inclusion criteria based on psychosocial problems and 5) lower quality studies. For subjective well-being and psychological well-being, there were no significant differences between subgroups, although for the latter there was a recognizable trend in the same direction and on the same moderators, except for quality rating.

Twenty-six out of 39 studies were self-help interventions for which we conducted a separate subgroup analysis. However, there was little diversity within the self-help subgroup: only six studies examined intensive self-help for longer than four weeks, self-help was offered to people with specific psychosocial problems in only one study and more than half of the self-help studies (n=14) recruited their participants via university. Consequently, there were no significant differences between subgroups for self-help interventions.

Publication bias

Indications for publication bias were found for all outcome measures, but to a lesser extent for subjective well-being. Funnel plots were asymmetrically distributed in such a way that the smaller studies often showed the more positive results (in other words, there is a certain lack of small insignificant studies). Orwin’s fail-safe numbers based on a criterium effect size of 0.10 for subjective well-being (59), psychological well-being (16) and depression (13) were lower than required (respectively 150, 110 and 80). Egger’s regression intercept also suggests that publication bias exists for psychological well-being (intercept=1.18, t=2.26, df=18, p=.04) and depression (intercept=1.45, t=2.26, df=12, p=.03), but not for subjective well-being (intercept=1.20, t=1.55, df=26, p=0.13). The mean effect sizes of psychological well-being and depression were therefore recalculated by imputing missing studies using the Trim and Fill method. For psychological well-being, three studies were imputed and the effect size was adjusted to 0.16 (95% CI 0.03-0.29). For depression, five studies were imputed and the adjusted effect size was 0.16 (95% CI 0.00-0.32).

Main findings

This meta-analysis synthesized effectiveness studies on positive psychology interventions. Following a systematic literature search, 40 articles describing 39 studies were included. Results showed that positive psychology interventions significantly enhance subjective and psychological well-being and reduce depressive symptoms. Effect sizes were in the small to moderate range. The mean effect size on subjective well-being was 0.34, 0.20 on psychological well-being, and 0.23 on depression. Effect sizes varied a great deal between studies, ranging from below 0 (indicating a negative effect) to 2.4 (indicating a very large effect). Moreover, at follow-up from three to six months, small but still significant effects were found for subjective well-being and psychological well-being, indicating that effects were partly sustained over time. These follow-up results should be treated with caution because of the small number of studies and the high attrition rates at follow-up.

Remarkably, effect sizes in the current meta-analysis are around 0.3 points lower than the effect sizes in the meta-analysis by Sin and Lyubomirsky (2009) [ 37 ]. We included a different set of studies in which the design quality was assured using randomized controlled trials only. Effectiveness research in psychotherapy shows that effect sizes are relatively small in high-quality studies compared with low-quality studies [ 35 ] and this might also be true for positive psychology interventions. In addition, we applied stricter inclusion criteria than those used by Sin and Lyubomirsky (2009) and therefore did not include studies on any related areas such as mindfulness and life review therapy. These types of interventions stem from long-standing independent research traditions for which effectiveness has already been established in several meta-analyses [ 40 , 41 ]. Also, the most recent studies were included. This might explain the overestimation of effect sizes in the meta-analysis by Sin and Lyubomirsky (2009).

Several characteristics of the study moderated the effect on depressive symptoms. Larger effects were found in interventions with a longer duration, in individual interventions (compared with self-help), when the interventions were offered to people with certain psychosocial problems and when recruitment was carried out via referral from a health care professional or hospital. Quality rating also moderated the effect on depression: the higher the quality, the smaller the effect. Interestingly, these characteristics did not significantly moderate subjective well-being and psychological well-being. However, there was a trend in the moderation of psychological well-being that was the same as that observed in the studies which included depression as an outcome. In general, effectiveness was increased when interventions were offered over a longer period, face-to-face on an individual basis in people experiencing psychosocial problems and when participants were recruited via the health care system.

Although it is clear that more intensive and face-to-face interventions generate larger effects, the effects of short-term self-help interventions are small but significant. From a public health perspective, self-help interventions can serve as cost-effective mental health promotion tools to reach large target groups which may not otherwise be reached [ 86 – 88 ]. Even interventions presenting small effect sizes can in theory have a major impact on populations’ well-being when many people are reached [ 89 ]. The majority of positive psychology interventions (in our study 26 out of 39 studies) are already delivered in a self-help format, sometimes in conjunction with face-to-face instruction and support. Apparently, self-help suits the goals of positive psychology very well and it would be very interesting to learn more about how to improve the effectiveness of PPI self-help interventions. However, a separate subgroup analysis on the self-help subgroup revealed no significant differences in the present meta-analysis. There was very little variation in the subgroups as regards population, duration of the intervention and recruitment method. As a result, this analysis does not give firm indications on how to improve the effectiveness of self-help interventions. It is possible that self-help could be enhanced by offering interventions to people with specific psychosocial problems, increasing the intensity of the intervention and embedding the interventions in the health care system. However, more studies in diverse populations, settings and with varying intensity are needed before we can begin to derive recommendations from this type of meta-analysis. Other research gives several additional indications on how to boost the efficacy of self-help interventions. Adherence tends to be quite low in self-help interventions [ 90 , 91 ] and therefore, enhancing adherence could be a major factor in improving effectiveness. Self-help often takes a ‘one size fits all’ approach, which may not be appropriate for a large group of people who will, as a consequence, not fully adhere to the intervention. Personalization and tailoring self-help interventions to individual needs [ 92 ] as well interactive support [ 93 ] might contribute to increased adherence and likewise improved effectiveness of (internet) self-help interventions.

Study limitations

This study has several limitations. First, the quality of the studies was not high, and no study met all of our quality criteria. For example, the randomization procedure was unclear in many studies. Also, most studies conducted completers-only analysis, as opposed to intention-to-treat analysis. This could have seriously biased the results [ 35 ]. However, the low quality of the studies could have been overstated as the criteria were scored conservatively: we gave a negative score when a criterion was not reported. Even so, more high-quality randomized-controlled trials are needed to enable more robust conclusions about the effects of PPIs. Second, different types of interventions are lumped together as positive psychology interventions, despite the strict inclusion criteria we applied. As expected, we found a rather high level of heterogeneity. In the future, it might be wise and meaningful to conduct meta-analyses that are restricted to specific types of interventions, for example gratitude interventions, strengths-based interventions and well-being therapy, just as has already been carried out with, for example, mindfulness and life review. In the present meta-analysis, studies on these specific interventions were too small and too diverse to allow for a subgroup-analysis. Third, the exclusion of non peer-reviewed articles and grey literature could have led to bias, and possibly also to the publication bias we found in our study. Fourth, although we included a relatively large number of studies in the meta-analysis, the number of studies in some subgroups was still small. Again, more randomized-controlled trials are needed to draw firmer conclusions. Sixth, the study of positive education is an emerging field in positive psychology [ 94 – 98 ] but school-based interventions were excluded from our meta-analysis due to the strict application of the inclusion criteria (only studies with randomization at individual level were included).

This meta-analysis demonstrates that positive psychology interventions can be effective in the enhancement of subjective and psychological well-being and may help to reduce depressive symptom levels. Results indicate that the effects are partly sustained at short-term follow-up. Although effect sizes are smaller in our meta-analysis, these results can be seen as a confirmation of the earlier meta-analysis by Sin and Lyubomirsky (2009). Interpretation of our findings should take account of the limitations discussed above and the indications for publication bias.

Implications for practice

In mental health care PPIs can be used in conjunction with problem-based preventive interventions and treatment. This combination of interventions might be appropriate when clients are in remission; positive psychology interventions may then be used to strengthen psychological and social recourses, build up resilience and prepare for normal life again. On the basis of the moderator analysis, we would recommend the delivery of interventions over a longer period (at least four weeks and preferably eight weeks or longer) and on an individual basis. Practitioners can tailor their treatment strategy to the needs and preferences of a client and can use positive psychology exercises in combination with other evidence-based interventions that have a positive approach and aim to enhance well-being, such as mindfulness interventions [ 40 ], Acceptance and Commitment Therapy [ 7 , 99 ], forgiveness interventions [ 42 ], behavioral-activation [ 100 ] and reminiscence [ 41 , 101 ].

In the context of public health, positive psychology interventions can be used as preventive, easily accessible and non-stigmatizing tools. They can potentially be used in two ways: 1) in mental health promotion (e.g. leaflets distributed for free at community centers, (mental) health internet portals containing psycho-education), and 2) as a first step in a stepped care approach. In the stepped care model, clients start with a low-intensity intervention if possible, preferably a self-directed intervention. These interventions can be either guided by a professional or unguided, and are increasingly delivered over the internet. Clinical outcomes can be monitored and people can be provided with more intensive forms of treatment, or referred to specialized care, if the first-step intervention does not result in the desired outcome [ 102 ].

Recommendations for research

Regarding the research agenda, there is a need for more high-quality studies, and more studies in diverse (clinical) populations and diverse intervention formats to know what works for whom. Standards for reporting studies should also be given more attention, for example by reporting randomized controlled trials according to the CONSORT statement [ 103 ]. In addition, we encourage researchers to publish in peer-reviewed journals, even when the sample sizes are small or when there is a null finding of no effect, as this is likely to reduce the publication bias in positive psychology. Furthermore, most studies are conducted in North America. Therefore, replications are needed in other countries and cultures because some positive psychology concepts may require adaptation to other cultures and outlooks (e.g. see Martinez et al., 2010) [ 68 ]. Last but not least, we strongly recommend conducting cost-effectiveness studies aiming to establish the societal and public health impact of positive psychology interventions. This type of information is likely to help policy makers decide whether positive psychology interventions offer good value for money and should therefore be placed on the mental health agenda for the 21 st century.

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We are grateful to Toine Ketelaars and Angita Peterse for the literature search and Jan Walburg for his comments on the manuscript. We would also like to thank Deirdre Brophy for the English language edit.

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LB conducted the meta-analysis, including the literature selection and data-analysis, and wrote the manuscript. MH took care of selecting the articles and cross-checking the data. All authors contributed to the design of the study. EB, GW, HR and FS are advisors in the project. All authors provided comments and approved the final manuscript.

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Bolier, L., Haverman, M., Westerhof, G.J. et al. Positive psychology interventions: a meta-analysis of randomized controlled studies. BMC Public Health 13 , 119 (2013). https://doi.org/10.1186/1471-2458-13-119

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Effects of Positive Psychology Interventions on the Well-Being of Young Children: A Systematic Literature Review

Affiliations.

• 1 Department of Special Education, University of Teacher Education, 1014 Lausanne, Switzerland.
• 2 Department of Development from Childhood to Adulthood, University of Teacher Education, 1014 Lausanne, Switzerland.
• PMID: 34831827
• PMCID: PMC8623229
• DOI: 10.3390/ijerph182212065

Over the last 20 years, the effectiveness of positive psychology interventions for the development of the well-being of children and adolescents and the moderation of high levels of anxiety and depression in this population has been largely demonstrated. Emphasis has been placed on the promotion of well-being and prevention of mental health problems in the school context in order to foster, through positive psychology, the cognitive and socio-emotional development of primary and secondary students, e.g., by strengthening positive relationships, positive emotions, character strengths, optimism, and hope. However, little is known about the impact of these interventions on young children. This systematic review aims at examining the effects of positive psychology interventions on the well-being of early childhood children (<6 years old), both in the preschool education context with educators or teachers and also in the family context with parents. Several electronic databases were searched, and the findings systematically reviewed and reported by the PRISMA guidelines. Very few studies met the inclusion criteria (n = 3), highlighting the need for further research in this area. Indeed, all of the selected studies demonstrated the importance of positive psychology interventions with young children to promote positive aspects of development, such as gratitude, positive emotions, life satisfaction, accomplishment, positive relationship, or self-esteem. Limitations in the field are discussed.

Keywords: early childhood; health prevention and promotion; positive psychology interventions; review; well-being.

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Conflict of interest statement

The authors declare no conflict of interest.

PRISMA flow diagram. * Reasons…

PRISMA flow diagram. * Reasons for exclusion included ineligible population (n = 15),…

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This systematic review assesses if positive psychology interventions (PPI) are more effective than other active psychological interventions for increasing the well-being of depressed adults. A review of randomised trials that compared PPI to other active interventions was conducted. A systematic search was undertaken using PsycInfo, PubMed, EMBASE, Web of Science, Scopus, CINAHL, two trial registries, and a manual search. The outcomes were happiness and depression. Ten studies, totalling 1341 participants, were included in the review. The small effect sizes for depression (Hedge’s g = 0.15) and happiness (Hedge’s g = 0.20) favoured PPI but were not significant, indicating no difference between PPI and other active interventions for the outcomes. Heterogeneity was high mainly due to differences in trial implementation. Risks of bias ranged from moderate to high. The results should be interpreted with caution because of the small number of included studies, high heterogeneity, and presence of bias.

Protocol Registration Number PROSPERO CRD42019152513.

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The effect of positive psychology interventions on well-being and distress in clinical samples with psychiatric or somatic disorders: a systematic review and meta-analysis

Do Positive Psychology Interventions Impact on the Subjective Wellbeing and Depression of Clients? A Systematic Methodological Review

A systematic review and meta-analysis of psychological interventions to improve mental wellbeing

Avoid common mistakes on your manuscript.

1 Introduction

Positive psychology sets itself apart from other psychological interventions by claiming that rather than merely treating mental health conditions, it builds positive resources that foster well-being (Seligman et al., 2006 ). A systematic review of randomised trials was planned to assess if positive psychology is more effective than other active psychological interventions for increasing the well-being of adults experiencing depression. Existing systematic reviews that relate to this topic have included studies using non-treatment or waitlist comparators (Bolier et al., 2013 ; Carr et al., 2020 ; Chakhssi et al., 2018 ; Hendriks et al., 2020 ; Sin & Lyubomirsky, 2009 ). In contrast, the present review only included trials that compared positive psychology interventions (PPI) to other active interventions.

Globally, more than 264 million people are affected by depression, making it one of the leading causes of disability (World Health Organisation, 2020 ). Yet an estimated 76% and 85% of people with depression in low- and middle-income countries respectively receive no treatment (World Health Organisation, 2020 ). The reasons could be non-availability or lack of access to treatment, or social stigma. The COVID-19 pandemic has exacerbated this situation. COVID-19 has affected people’s mental health globally (Waters et al., 2021 ; Xiong et al., 2020 ). However, those who are affected might not be able to access timely mental health support due to lockdowns and service closures. It has thus become more pressing to find an effective intervention that can be self-administered or delivered remotely. In this regard, compared to other active interventions, PPI is low-cost and low intensity; hence it can be applied on a wider scale with less resources. It is therefore worthwhile comparing PPI’s effectiveness to other active interventions to ascertain its viability as an alternative approach to supporting people living with mental health conditions.

2 Background

2.1 positive psychology and increasing well-being.

The positive psychology movement emerged in the wake of psychology’s overwhelming emphasis on pathology. Seligman and colleagues (Csikszentmihalyi & Seligman, 2000 ; Seligman et al., 2006 ) observed that since the end of the Second World War, research in psychology had been dominated by the study of mental illness. They argued (Csikszentmihalyi & Seligman, 2000 ; Seligman, 1999 ; Seligman et al., 2006 ) that while it was important to study pathology, this almost exclusive focus on diseases and their treatments benefitted only a minority of people suffering from mental health conditions. Seligman and his colleagues saw this as veering away from psychology’s original mission of bettering the lives of all people, hence their launch of the positive psychology movement.

The positive psychology movement quickly gave rise to the development of PPI—an umbrella term for activities that promote positive thoughts, emotions and behaviours with the long-term goal of contributing to psychological growth and well-being (Sin & Lyubomirsky, 2009 ; Sin et al., 2011 ; Schrank et al., 2014 , 2016; Sutipan et al., 2017 ; Hendriks et al., 2018 ). The form PPI takes ranges from one single activity, such as gratitude journaling or performing an act of kindness (Kerr et al., 2015 ; Otake et al., 2006 ), to a multi-component intervention, such as the Positive Psychotherapy programme (Seligman et al., 2006 ; Rashid, 2015 ), which consists of a series of activities organised into 14 sessions.

Over the last three decades, evidence supporting PPI’s effectiveness has been accruing. PPI has been shown to both reduce depression and promote well-being and optimal functioning for the general population, mental health groups, and patients suffering from chronic or terminal illnesses. Sin and Lyubomirsky ( 2009 ) published the first systematic review on PPI’s effects on depression and well-being. They included 51 interventions in their meta-analysis, which yielded significant medium effect sizes of r = 0.29 and 0.31 in favour of PPI for improved well-being and reduced depression. Sin and Lyubomirsky ( 2009 ) interpreted the results as evidence of PPI’s effectiveness. However, they noted significant heterogeneity among their studies, which they addressed by analysing moderator effects. The moderator analyses showed PPI to work better for participants with depression compared to non-depressed participants, although this could be the result of a flooring effect. PPI was more effective for self-referred participants and older participants. It also worked better when delivered as individual therapy compared to group and self-administered formats.

Sin and Lyubomirsky’s ( 2009 ) lack of quality appraisal and their inclusion of quasi-experimental designs might have resulted in their effect sizes being overestimated due to lower study quality. Bolier et al. ( 2013 ) conducted a similar review but selected only randomised controlled trials (RCT). They also critically appraised their included studies to assess risk of bias. They meta-analysed 39 studies and found significant small to medium effects of d = 0.34, 0.20, and 0.23 for subjective well-being, psychological well-being, and depression respectively. The effect sizes were reduced at follow-up assessments, although still significant. Bolier and colleagues cautioned that the quality of most studies were low to medium (20 low, 18 medium, 1 high), so even with the modest effect sizes, they could still have been inflated. Their review found moderator effects, two of which echoed the results of Sin and Lyubomirsky ( 2009 ). These were larger effects found for individual-based interventions and among participants with specific psychosocial problems. In addition, Bolier et al. ( 2013 ) found larger effects for longer duration interventions and for participants who were recruited through hospitals or healthcare professionals.

Hendriks et al.’s ( 2020 ) systematic review, which focused on the effects of multi-component PPI, also selected RCTs only. The meta-analyses of 50 studies yielded small to moderate effect sizes for subjective well-being (g = 0.34), psychological well-being (g = 0.39) and depression (g = 0.32). However, compared to Boiler et al., there were more studies in Hendricks et al.’s review that were assessed to be of moderate and high quality (13 high, 21 moderate, 16 low), and the effects were reduced when the low quality studies were removed from the analyses.

In another review by Hendriks et al. ( 2018 ) on the efficacy of PPI in non-Western populations to evaluate the cross-cultural validity of PPI, the reviewers meta-analysed 28 RCTs mostly conducted in Middle Eastern and East and South Asian countries. Effect sizes at post-treatment were moderate to large for all outcomes vis-a-vis the mostly smaller effect sizes in Western studies. However, the authors cautioned that most of the reviewed studies were of low quality (23 low, 2 medium, 3 high quality), and heterogeneity was significant in all the comparisons. Hence, the effects were most likely overestimated.

Finally, in their systematic review, Carr et al ( 2020 ) attempted to overcome the shortcomings of previous reviews by setting more inclusive eligibility criteria. They included clinical and non-clinical populations, as well as various PPI types and format, different mental health conditions, age groups (including children), countries (including non-western countries), and publication types and publication languages. This yielded 347 included studies with more than 72,000 participants. The meta-analyses produced medium effects for well-being (g = 0.39) and depression (g = −0.39). With regard to study quality, as with previous reviews, the included studies were mostly rated as fair (152 studies) or low in quality (164 studies).

By including both general and clinical populations in their reviews, Sin and Lyubomirsky ( 2009 ), Bolier et al. ( 2013 ), Hendricks et al. ( 2020 ; 2018 ) and Carr et al. ( 2020 ) provided a broad-spectrum view of PPI’s effectiveness. Other syntheses have focused on specific groups. For examples, Schrank et al.’s ( 2014 ) narrative literature review discussed how PPI supported recovery from mental health conditions. Likewise, Walsh et al. ( 2017 ) conducted a systematic review on studies that included only individuals who had been formally diagnosed or had met the assessment criteria for depressive or psychotic disorders. Santos et al.’s ( 2013 ) systematic review addressed PPI’s effectiveness on treating depression. Generally, the results of these reviews converged on PPI being effective in reducing negative symptoms and increasing well-being. Meta-analysis was not conducted in these reviews. On the other hand, Chakhssi and colleagues ( 2018 ) meta-analysed 30 studies that tested PPI among clinical populations diagnosed with psychiatric or somatic illnesses. The meta-analyses yielded small effects for increasing well-being and reducing depression, as well as a moderate effect for reducing anxiety. As with other reviews, the quality of studies in Chakhssi et al.’s review ranged from low (n = 18) to medium (n = 12). After removing the low-quality studies, the effect sizes were reduced to non-significant for depression and anxiety.

Thus far, the accumulative evidence from the systematic reviews cited above points to PPI being moderately beneficial for enhancing well-being and reducing depression, and PPI being more effective as individual therapy, over a longer period of time, and when a variety of activities are practiced instead of a single activity.

2.2 Positive Psychology vs. Other Active Interventions

Positive psychology’s major doctrine is that the absence of negativity does not directly imply the presence of positivity (Lee Duckworth et al., 2005 ; Seligman et al., 2006 ). In other words, not being mentally ill (the absence of depressive symptoms) does not automatically bring forth happiness (the presence of positivity). Merely recovering from a mental health condition is therefore insufficient if well-being is not gained and enhanced as well. On this premise, positive psychologists distinguish PPI from other standard psychological interventions by stating that while other interventions mainly target negative symptoms, PPI promotes positive thoughts, feelings and behaviours, which in turn creates sustainable recovery and long-term well-being (Lee Duckworth et al., 2005 ; Seligman et al., 2006 ). Should this claim be true, one would expect PPI and other active interventions to be equally effective in reducing negative symptoms, but PPI to fare better in promoting well-being. However, to date, systematic reviews examining the effectiveness of PPI have included trials that mostly compared PPI to no-treatment or wait-list (for example, Bolier et al., 2013 ; Chakhssi et al., 2018 ; Sin & Lyubomirsky, 2009 ). Systematic reviews that solely compare PPI with other active psychological interventions are limited and fairly recent (Carr et al., 2020 ; Geerling et al, 2020 ).

Furthermore, individual trials that directly compared PPI with another active intervention have shown mixed results. Furchtlehner et al.’s ( 2019 ) RCT comparing group-based PPI and group-based Cognitive-Behavioural Therapy (CBT) for treating depression found PPI to fare significantly better. Conversely, another trial by Chaves et al. ( 2017 ) showed no difference between group-based PPI and group-based CBT on all outcomes. It would be beneficial to synthesise these and similar studies to clarify the matter. Such a comparison has important practical implications. PPI is relatively low-cost, requires less training to administer, and can be self-administered. Therefore, it can be implemented more cost-effectively and on a larger scale, compared to other active techniques. In situations where it may be costly to provide standard treatments or in resource-deprived places where patients are unable to access standard treatments, positive psychology could be a viable alternative (Layous et al., 2011 ).

As mentioned, there has not been any systematic review comparing only PPI and another active psychological treatment until recently (Carr et al., 2020 ; Geerling et al., 2020 ). In their review, Carr et al. ( 2020 ) analysed comparators as moderators. They found smaller effect sizes when PPI was compared to other active interventions (well-being g = 0.31; depression g = −0.30) than when PPI was compared to no-treatment controls (well-being g = 0.55; depression g = −0.52). On the other hand, Geerling et al.’s ( 2020 ) review did not find significant differences between PPI and active interventions for both outcomes. However, these two reviews are not comparable. Carr et al.’s ( 2020 ) review was wide-ranging as previously mentioned, while Geerling et al. ( 2020 ) studied only adults who were suffering from severe mental illness such as major depression, schizophrenia and bipolar disorder.

The wide-ranging focus of Carr et al.’s ( 2020 ) review limits its ability to inform specific practical applications. Moreover, it only searched databases until Dec 2018. Furthermore, Geerling et al. ( 2020 ) focused on a clinical population, meaning findings are not necessarily transferable to community dwelling adults. The review presented below addressed these issues.

3 The Present Study

In light of the foregoing discussion, a systematic review was conducted on the effectiveness of PPI compared to other active psychological interventions for improving the well-being of adults with depression. It excluded studies that used no-treatment, waiting list, or non-active interventions as comparators. It was hypothesised that PPI would be more effective than other active comparators for improving the well-being of adults experiencing depression. It was also hypothesised that there would be no difference between PPI and other active treatments in reducing depressive symptoms. Depression was selected for the review because PPI has most often been used to treat it compared to other mental health conditions.

The review was conducted according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) and the Cochrane Handbook for Systematic Reviews of Interventions’ guidelines (Higgins et al., 2019 ). Its protocol was registered on PROSPERO, an international register of systematic reviews (registration number CRD42019152513).

4.1 Search Strategy

Electronic database searches were carried out on PsycINFO, PubMed, EMBASE, Scopus, Web of Science, and CINAHL, as well as two trial registers— www.clinicaltrialsregister.eu , and www.clinicaltrials.gov , on 10 April 2019. Updated searches were conducted on 15 November 2019 and 1 May 2020. Text word search terms such as “positive psychology”, depress*, well-being, random*, trial, and their variations were used to search the title and/or abstract fields. Names of individual positive psychology activities (e.g. gratitude, optimism) were also included as search terms. The search strategy varied slightly according to each database’s setting and requirements. Besides the databases and trial registers, references of published reviews (Bolier et al., 2013 ; Chakhssi et al., 2018 ; Hendriks et al., 2018 ; Santos et al., 2013 ; Sin & Lyubomirsky, 2009 ; Sutipan et al., 2017 ; Walsh et al., 2017 ) were searched. There was no restriction on publication dates.

4.2 Selection of Studies

Eligible studies were selected in two phases. The first was title and abstract screening, and the second a full text review. The first author conducted both phases. Included and excluded studies were then checked by another independent reviewer. Apart from a few minor clarifications on the tools used to assess depression, there was no major disagreement over study inclusion or exclusion. Studies were selected to be included in the review according to the following criteria:

4.2.1 Study Design

RCTs with at least two arms, one providing PPI and the other providing another active psychological intervention.

4.2.2 Participants

Participants had to be adults (18 + years) and ascertained by validated assessment tools to have clinical or non-clinical depression. Participants must not be receiving institutionalised care for their depression. This is because institutionalised patients would most likely be receiving structured psychiatric treatments that may confound the review’s results. Studies that examined other mental health conditions, such as anxiety disorders and dementia, or included participants with multiple mental health conditions, were excluded. However, studies that included different groups of participants were selected if they included participants that fitted the eligibility criteria and if the outcomes for participants with depression were reported separately and could be extracted for review.

4.2.3 Outcomes

The outcomes were well-being and depression. Well-being could be measured as subjective well-being, psychological well-being or happiness.

4.2.4 Language

Studies had to be published in English.

4.3 Data Management

Two softwares, Zotero and RevMan , were used for data management. Initially, all search results were exported to Zotero , a reference managing software, to enable offline title and abstract screening, as well as full text review. Zotero was also used to identify and merge duplicates before screening. The included studies were then added into RevMan for data extraction and analyses.

4.4 Data Extraction

The following data were extracted: (1) participant characteristics (age, gender, depression status), (2) intervention and comparator characteristics (sample size for each arm, activity type, frequency, duration, format), (3) outcomes (types of outcome and methods of measurement), and (4) country in which the trial was conducted. The extracted data were stored in RevMan . Eight authors from seven studies (Asgharipoor et al., 2012 ; O’ Leary & Dockray, 2015 ; Uliaszek et al., 2016 ; Broc et al., 2017 ; Celano et al., 2017 ; Chaves et al., 2017 ; Furchtlehner et al., 2019 ) were contacted to either clarify information or request data. Two responded, five did not, while one could not be reached as the email address listed on the paper no longer worked.

4.5 Risk of Bias

Risk of bias for included studies was assessed using the Cochrane Risk of Bias tool (Higgins et al., 2011 ). The domains of assessment are sequence generation (selection bias), allocation concealment (selection bias), blinding of participants and personnel (performance bias), blinding of assessment (detection bias), incomplete outcome data (attrition bias), selective reporting (reporting bias) and other biases such as bias as a result of deviation from treatment.

While reviews such as Bolier et al. ( 2013 ) took a more conservative approach to critical appraisal, in which non-report of a criterion was given a negative rating, the current review rated similar studies as unclear. This was because it was expected that many behavioural science publications might not follow a standard reporting template (e.g., CONSORT), therefore when a critical appraisal criterion, such as allocation concealment, was not reported, one should not assume that it has not been done; thus an “unclear” rating was deemed appropriate.

4.6 Data Analysis

Post-intervention scores were used for meta-analysis of intervention trials. The meta-analysis for each outcome was conducted using the random effects model as the studies were expected to be heterogeneous. The outcomes were expected to be measured as continuous variables, and by different measurements, hence standardised mean differences (Hedge’s g) were computed as the effect size. Following Hendrik et al.’s ( 2018 ) convention, effect sizes of 0–0.32 was considered as small, 0.33–0.55 as moderate, and 0.56–1.2 as large. Positive effect sizes would indicate treatment effects favouring PPI while negative effect sizes would indicate treatment effects favouring comparators.

Depression and well-being were expected to be measured with multiple measures. In such situations, when studies used more than one measure to assess the outcomes, the measures to be used for meta-analysis were selected based on conceptual similarity. This was so that the conceptual integrity of the construct could be preserved. In this way, the results could be interpreted more meaningfully.

Heterogeneity was assessed with the Q statistic and I 2 statistics. A statistically significant Q statistic at p  = 0.05 indicates heterogeneity among the studies. As for the interpretation of I 2 , Higgins et al’s ( 2019 ) convention was adopted, where:

I 2  = 0–40%: might not be important;

I 2  = 30–60%: may represent moderate heterogeneity;

I 2  = 50–90%: may represent substantial heterogeneity;

I 2  = 75–100%: considerable heterogeneity.

Sensitivity analyses were performed to examine if the main results were affected by studies with small sample sizes and studies that did not fully meet the selection criteria but were included in the review. This was done by repeating the meta-analyses with such studies excluded. In addition, as recommended by Higgins et al. ( 2019 ), the fixed effects and random effects models were compared to test for small studies effect.

Publication bias was assessed by a funnel plot diagram. An asymmetry on the funnel plot suggests the presence of publication bias. Asymmetry was also assessed using Egger’s test. The funnel plot and Egger’s test are the two tests of publication bias recommended by Higgins et al. ( 2019 ) and Sterne et al. ( 2011 ) to be sufficient for assessing publication bias. More importantly, instead of relying on post-hoc statistical tests, Sterne et al. ( 2011 ) stressed the importance of conducting a systematic and comprehensive search to minimise publication bias. In this review, publication bias was addressed with a more extensive search than previous reviews. It searched six databases compared to fewer databases searched by other reviews. It also searched two trial registers to check for unpublished trials. Names of individual PPI activity were used as search terms to further expand the search. However, publication bias could still exist because we did not search for grey literature.

5.1 Study Selection

The search retrieved a total of 2148 results, of which 1982 were from databases, 144 from trial registers and 22 from searching the references of existing reviews. A total of 1031 references remained after the removal of duplicates. These were screened by title and abstract, which in turn led to 51 studies being selected for full text screening. The main reason for exclusion at the title and abstract screening stage was the use of no-treatment comparators. Full-text screening of the 51 studies resulted in ten being included in the review. The selection process is depicted in the flow diagram in Fig.  1 .

Flow diagram of study selection process

One of the included studies, O’ Leary and Dockray ( 2015 ), did not specify that their participants were diagnosed or assessed as having depression. However, it can be inferred from the participants’ baseline depression scores that they were experiencing depression. The Edinburgh Postnatal Depression Scale (EDS) was used to assess depression in their participants. For this tool, a score of 10 and above indicates mild or major depression (Cox et al., 1987 ). In O’Leary and Dockray’s ( 2015 ) study, all three groups registered baseline scores of more than 20. The baseline means and standard deviations were 20.08 and 5.21 for the Gratitude group, 20.44 and 3.94 for the Mindfulness group, and 20.17 and 5.85 for the Control group. It is therefore apparent that the participants were experiencing depression at baseline, making the study eligible for review.

Another study, Uliaszek et al. ( 2016 ), included participants with multiple diagnoses. As the majority of the participants (71%) had a diagnosis of major depressive disorder or dysthymic disorder, changes in depression symptoms as measured by the Symptom Checklist-90 Revised (SCL-Dep) were likely due to this group of depressed participants. Therefore, the study was included, but only in the analysis for depression. It was not used for the analyses for well-being. This was because it is likely that participants with other diagnoses contributed to the well-being outcome as well, which would have contravened the review’s selection criteria.

5.2 Study Characteristics

Table 1 presents the characteristics of the ten included studies. One was conducted in Iran (Asgharipoor et al., 2012 ), one was based in Canada but included globally diverse participants as its intervention was delivered online (Mongrain et al., 2016 ). The rest were conducted in Northern America and Europe. In total, the ten trials evaluated 1341 participants assessed to have mild to severe depression. There were 529 participants in the PPI arm and 812 in the comparator arm. The interventions were group-based in four of the trials. Out of the remaining six individualised interventions, four were self-administered and two were conducted by interventionists. One of these two was centre-based while the other was delivered over the phone. One study used only gratitude exercise as the PPI (O’Leary & Dockray, 2015 ), the rest included a variety of activities in their PPI. The most common comparator was CBT, used by five of the studies. This was not surprising as CBT is the treatment of choice for depression (National Institute for Health and Care Excellence, 2019 ). The comparators for the remaining five studies were mindfulness therapy, dialectic behavioural therapy, cognitive-focused exercises and unspecified active psychotherapies (“Treatment as usual”). Five studies (O’ Leary & Dockray, 2015 ; Mongrain et al., 2016 ; Celano et al., 2017 ; Furchtlehner et al., 2019 ; & Hanson, 2019 ) measured the outcomes at follow-up between two weeks and six months post-intervention, in addition to assessments at baseline and post-intervention. The other five studies measured the outcomes at baseline and post-intervention only (Asgharipoor et al., 2012 ; Chaves et al., 2017 ; Seligman et al., 2006 ; Uliaszek et al., 2016 ; Walker & Lampropoulos, 2014 ).

5.3 Risk of Bias

The risk of bias assessment is summarised in Table 2 . All studies presented unclear or high risk of bias for allocation concealment, performance bias, and reporting bias. Most did not report whether steps were taken to conceal group allocation from the participants (selection bias), or to blind participants to treatment (performance bias). Published protocols could not be found for the studies except for Furchtlehner et al. ( 2019 ), therefore reporting bias could not be ascertained. As for detection bias (assessment bias), only one study (Celano et al., 2017 ) reported using blinded assessors. The other nine studies clearly or very likely had participants self-completing most of the outcome assessment questionnaires. These studies were rated as presenting low risk of detection bias (Cook, 2010 ). It should be noted that in Furchtlehner et al.’s ( 2019 ) study, one of the investigators was involved in the intervention at one of their trial sites, potentially contributing to performance bias. The same investigator was also involved in data collection at the same site. However, as the data were collected via self-report, the risk of detection bias was still rated as low.

5.4 Selection of Outcome Measures

As shown in Table 1 , the questionnaires used to measure well-being and depression differed from study to study, and all studies used multiple questionnaires to measure the outcomes. Among the different tools used to measure well-being, scales that measured happiness were consistently used in all the included studies. Therefore, based on the selection principle of conceptual convergence, happiness was chosen as the well-being variable to be meta-analysed. The other measures of well-being were too varied for the small number of studies.

As for depression, Walker and Lampropoulos ( 2014 ), Furchtlehner et al. ( 2019 ) and Seligman et al. ( 2006 ) used multiple measures, while the remaining studies used one measure. Beck’s Depression Inventory (BDI-II) was most commonly used (Asgharipoor et al., 2012 ; Chaves et al., 2017 ; Furchtlehner et al., 2019 ; Hanson, 2019 ), followed by the Centre for Epidemiological Study Depression Scale (CES-D) (Mongrain et al., 2016 ; Walker & Lampropoulos, 2014 ). Both BDI-II and CES-D were thus selected for the meta-analysis together with four other measures that were used individually by the remaining four studies (Seligman et al., 2006 ; O’ Leary & Dockray, 2015 ; Uliaszek et al., 2016 ; Celano et al., 2017 ).

5.5 Meta-Analysis

5.5.1 post-intervention effects.

The meta-analyses results are summarised in Table 3 . The effect for happiness favoured PPI but was not significant, Hedge’s g = 0.20 (95% CI = −0.12, 0.53), overall effect Z = 1.22, p  = 0.22. There was substantial heterogeneity, Q = 30.40, p  = 0.002; I 2  = 74%. Similarly, for depression, the effect favoured PPI but was not statistically significant, Hedge’s g = 0.15 (95% CI = −0.19, 0.49), overall effect Z = 0.86, p  = 0.39. Heterogeneity among the studies was also substantial, Q = 42.53, p  = 0.00001, I 2  = 79%. The results indicated no real difference in effectiveness between PPI and the comparators in either treating depression or increasing happiness.

5.5.2 Sensitivity Analysis

There was initial evidence of small studies effect in the meta-analyses. For both outcomes, the two smallest studies (Asgharipoor et al., 2012 ; Seligman et al., 2006 ) produced larger effect estimates than all the other studies except Furchtlehner et al. ( 2019 ). The meta-analyses were repeated with these two studies removed. Their removal did not significantly alter the results for either outcome. Higgins et al. ( 2019 ) recommended comparing fixed-effects and random-effects analyses when small studies effect is suspected and heterogeneity is present. Similar effect estimates between the two analyses implies that the small studies have little effect on the results. In this case, when the fixed-effects model was applied, the effect estimates for both outcomes became significant. However, the significant results were due to the disproportionate influence of the largest study (Mongrain et al., 2016 ). Therefore, although the fixed effects and random effects analyses produced different results, the results remain inconclusive.

As mentioned in the study selection section, two studies (O’ Leary & Dockray, 2015 ; Uliaszek et al., 2016 ) were included in the review although they did not fully meet the eligibility criteria. Thus, the meta-analyses were repeated with these two studies removed in turn. The results were not significantly altered, indicating that the addition of these two studies did not skew the results.

5.6 Publication Bias

Figures  2 and 3 in the supplementary materials display the funnel plots of the two outcomes. Both funnel plots are asymmetrical—indicative of publication bias. The bias appears to be more pronounced for happiness than for depression, as the funnel plot for happiness deviates more from symmetry than depression. Specifically, the two smallest studies (Asgharipoor et al., 2012 ; Seligman et al., 2006 ) show moderately high precision of effect estimates for happiness, compared to depression for which these two studies reside on the base of the funnel plot, indicating low precision of effect estimates. Egger’s test was conducted to test the significance of the asymmetry. Both regression lines did not pass through the point of origin, indicating asymmetry. The intercept for happiness is below zero, revealing possible small studies effect (Egger et al., 1997 ). However, both the regression intercepts for happiness (intercept = −0.511, 93% CI = −1.812, 0.789) and depression (intercept = 0.363, 95% CI = −0.912, 1.638) were not significant. The results of the funnel plots and Egger’s tests have to be interpreted with caution. Sterne et al. ( 2011 ) recommended that funnel plots should only be done when there are at least ten studies, and this minimum number increases with higher heterogeneity. Therefore, the small number of studies and high heterogeneity may have likely limited the validity of the funnel plot. In a similar vein, Sterne et al. ( 2011 ) also advised against doing the Egger’s test if there are less than ten studies. Moreover, when there is substantial between-study heterogeneity, statistical tests for asymmetry tend towards being underpowered. For these reasons, publication bias could not be fully ascertained from the funnel plots and Egger’s tests. The asymmetries might more likely be due to heterogeneity, reporting bias and chance.

Funnel plot for depression

Funnel plot for happiness

6 Discussion

This study systematically reviewed PPI’s effectiveness for increasing the well-being of depressed adults compared to other active psychological interventions. Its outcomes were improvement in well-being (happiness) and reduction in depression. It was hypothesised that firstly, PPI would fare better than other active psychological interventions for enhancing well-being, and secondly, PPI and other active psychological interventions would produce similar effects for reducing depression. The results supported the second but not the first hypothesis. The effect sizes of 0.20 for happiness (well-being) and 0.15 for depression were small and non-significant, suggesting no difference in effectiveness between PPI and other active interventions for reducing depression and enhancing well-being.

The effect size for happiness is the same as Bolier et al.’s ( 2013 ) 0.20 for psychological well-being, but smaller than other reviews (Carr et al., 2020 ; Hendriks et al., 2020 ; Chakhssi et al., 2018 and Sin & Lyubomirsky, 2009 ) where g = 0.28 to 0.39. The effect size of 0.15 for depression is smaller than that of the above reviews in which effect sizes ranged from 0.27 to 0.39. Moreover, the effects in those reviews were statistically significant, whereas this was not so for both effect sizes in the present review. This is not surprising given that the other reviews had many more included studies and a majority of non-treatment comparators.

With regards to comparing PPI with other active interventions, Carr et al.’s ( 2020 ) comparisons were statistically significant, g = 0.31 for well-being and g = −0.30 for depression; in contrast, effect sizes were not significant in the present review. Carr et al. ( 2020 ) had 226 studies that were highly mixed in study characteristics and study quality, which might have inflated the effect sizes. Comparatively, our review is closer to Geerling et al.’s ( 2020 ) in selection criteria and scope, and both reviews yielded non-significant results.

Contrary to the claim that PPI enhances well-being while other active interventions merely target depressive symptoms, our review did not find PPI to fare significantly better than active comparators in increasing happiness, despite the results favouring PPI. There could be a few possible reasons for this. It could be due to the small number of included studies and the modest sample sizes of most of those studies, making the review insufficiently powered to detect any significant effect. More and bigger trials are therefore needed. It could also be that common factors such as therapeutic alliance and patient expectancy (placebo effect) contributed more to the positive outcomes than the intervention itself (Ahn & Wampold, 2001 ).

At the same time, it could be that other active interventions are also capable of enhancing well-being. Two studies that examined CBT’s mechanism of change in treating panic disorder showed that increase in self-efficacy was a crucial step towards treatment efficacy (Fentz et al., 2013 ; Gallagher et al., 2013 ). This demonstrates the ability of CBT to not only alter faulty cognition but also cultivate positive cognition.

Perhaps the uniqueness of positive psychology in increasing positivity compared to other standard treatments holds true only under specific conditions. For instance, at present many psychological interventions focus on either remedying the past (e.g., psychoanalysis) or bettering the present (e.g., behavioural modification, mindfulness). Positive psychology contrasts with these interventions by accentuating the importance of being positive about not just the past and the present but also the future. Cultivating future-oriented positive cognition and emotion such as optimism and hope may be positive psychology’s unique contribution to mental health.

6.1 Heterogeneity

There was substantial heterogeneity in both comparisons. This might occur from two main sources. The first was the wide variation in intervention implementation. There were assortments of group- and individual-based, in-person and online, as well as guided and self-help formats. For intervention content, there were single activity and multiple activities, as well as manualised and non-manualised activities. Furthermore, intervention duration and frequency differed from one trial to another. There were also within-trial individual differences in implementation. For example, Seligman et al., 2006 tailored their PPI activities according to an individual participant’s clinical needs, circumstances and feasibility of completing the activities. In Walker and Lampropoulos’ ( 2014 ) study, participants were allowed to decide how many activities to complete, with a minimum requirement of completing four activities. Participants were also asked to participate in self-chosen social and volunteering activities as part of the intervention, which would inevitably result in differences in how and where they went about completing the activities. Such differences distributed among a small number of studies would unavoidably give rise to sizeable heterogeneity. This heterogeneity can be gradually lessened when more studies adhere to uniform intervention format and content. However, doing so would compromise external validity, as calibrating an intervention according to patients’ characteristics and context is essential for psychological treatments.

The second source of heterogeneity could be the different ways in which well-being was operationalised and measured. To overcome this limitation, our review adopted the method of selecting measures that converged conceptually. It resulted in happiness being selected as the well-being measure for the meta-analysis. Other measures of well-being in the included studies were too varied. Going forward, researchers can consider adopting more common measures of well-being.

6.2 Risk of Bias

The result of the risk of bias assessment did not differ much from other reviews of PPI (Bolier et al., 2013 ; Chakhssi et al., 2018 ; Hendriks et al., 2018 ). It revealed an overall moderate to high risk of bias. Table 2 shows that allocation concealment, blinding participants and personnel, blinding of outcome assessment, and reporting could be further tightened. Nevertheless, blinding interventionists and participants may not be possible in psychological interventions. In these situations, it may be reasonable for reviewers to consider removing these two criteria or scoring them as “Not Applicable”. The same can be said of blinding of outcome assessment when outcome assessments are self-administered (e.g., see Bolier et al., 2013 ; and Sutipan et al., 2017 ). Alternatively, reviewers can consider rating studies that use self-report as low on assessment bias, according to Cook’s ( 2010 ) argument that self-report minimises the risk of assessment bias.

6.3 Implications for Mental Health Practice

Previous reviews (Bolier et al., 2013 ; Sin & Lyubomirsky, 2009 ) have suggested that people experiencing mild to moderate depression, as well as those whose depression is in remission, can benefit from PPI. Specifically, these reviews showed greater benefits when PPI is delivered at the individual level instead of in groups, when it is clinician-guided instead of self-administered, when it comprises multiple activities instead of a single activity, and when it is done over a longer rather than shorter period.

Until the present review, synthesis of evidence to examine whether PPI can be a viable substitute for traditionally preferred psychological treatments of depression was scarce. Our review adds to this body of knowledge by providing further evidence that PPI can be a low-intensity, low-cost replacement for traditionally preferred depression treatments. The results favoured PPI over the active comparators although they failed to attain statistical significance. However, the accumulative evidence attests to PPI’s prospects in benefitting people with mental health conditions who are unable to access standard treatments. The COVID-19 pandemic is an example of such a scenario.

COVID-19 has affected the world on an unprecedented scale in modern history. It is not just a health pandemic; it has also created a mental health pandemic (Waters et al., 2021 ). While more research is required to understand the long-term mental health impact of COVID-19, and the corresponding responses that are needed (Holmes et al., 2020 ), the current situation calls for research-supported interventions that can be implemented efficiently under pandemic conditions. This means interventions that can be self-directed or remotely guided, delivered on a large scale in a community, and are simple and easily accessible. Most importantly, besides maintaining and improving mental wellness, these interventions must provide people caught in a bleak situation with a sense of hope (Waters et al., 2021 ). PPI has much to offer in this respect, and is adaptable, simple to use and appropriate for self-help.

However, reviews by Bolier et al. ( 2013 ) and Sin and Lyubomirsky’s ( 2009 ) showed that PPI is less effective when self-administered compared to clinician-guided, individual sessions. More precise studies are needed to compare the usefulness of self-administered and clinician-guided PPI because there may be other factors that better predict PPI effectiveness, such as patient motivation and commitment. Self-administered PPI may suit patients who value flexibility while clinician-guided therapy may work better for those who require structure and accountability.

Nevertheless, on this note, Layous et al. ( 2011 ) argued that self-administration is more feasible in situations where there is a need for widespread implementation of an intervention, such as during a pandemic lockdown. Therefore, self-administered PPI is still worthwhile in situations where access to guided interventions is limited. Moreover, Bolier et al. ( 2013 ) added that an intervention with a small effect can still create a sizable impact when there is a wide reach. More importantly, Bolier et al. ( 2013 ) also noted the need to study how to increase the effectiveness of self-help PPI, as doing so is well-aligned with positive psychology’s aim for PPI to be self-directed for most people. In addition, hybrid delivery modes can also be explored, such as a self-administered PPI with scheduled clinician check-ins.

6.4 Limitations

The number of studies included in the review was small, and the sample sizes in many of these studies were modest. As a result, the analyses were underpowered to produce significant effects, thus precluding any firm conclusions. More and bigger trials are needed to add to its findings. Secondly, the substantial heterogeneity and presence of biases could have resulted in overestimation of the effects. Future trials may want to explore ways to decrease heterogeneity and bias. Thirdly, despite conducting a more extensive search compared to previous reviews, publication bias could not be ruled out because the search strategy did not include studies published in non-English languages and grey literature. Fourthly, not all studies conducted follow-up outcome assessments, hence the intermediate to long-term sustainability of the outcomes could not be fully evaluated. Furthermore, there was insufficient data to examine moderator effects, which could otherwise have shed more light on whether PPI worked better for certain groups of patients or under certain conditions. Nevertheless, moderator analyses conducted by previous reviews have provided considerable insights into the issue (e.g., Boiler et al., 2013 ; Sin & Lyubomirsky, 2009 ). Finally, only one author conducted the screening of studies, although a second reviewer checked the included and excluded studies. This could pose a potential source of bias as there was a lack of a second reviewer to conduct the screening of studies independently.

6.5 Future Research

In response to the limitations, improvements are possible in future research. Firstly, heterogeneity could be reduced by implementing manualised PPI such as the Positive Psychotherapy programme (Seligman et al., 2006 ; Rashid, 2015 ). Another way to reduce heterogeneity is to use conceptually similar measures to assess the outcomes. Secondly, in terms of bias, although blinding interventionists and participants cannot be realistically done in most situations, other criteria can still be ensured by implementing trials more scrupulously and reporting them more thoroughly. Specifically, areas that can be strengthened include detailed reporting of random sequence generation, implementing allocation concealment and reporting the procedure, and publishing trial protocols. For assessment bias, when self-report is used or assessors cannot be blinded, it is important to ensure that standardised and psychometrically validated measures are used, and that assessors are properly trained to conduct the assessment (de Oliveira Souza et al., 2016 ; Sedgwick, 2015 ). There is also a need for more trials that conduct follow-up assessments to examine the intermediate to long-term sustainability of the effects. Finally, future trials can look into PPI’s mechanisms of change, besides merely studying whether it works. Lyubomirsky and Layous ( 2013 ) proposed a person-activity fit model that spells out activity- and person-related factors that moderate the effectiveness of positive activities on well-being. The authors asserted that the best result is achieved when there is an optimal fit between person and activity. Future trials could set out to test and refine Lyubomirsky and Layous’ ( 2013 ) model.

7 Conclusion

The results of this systematic review did not support the claim that PPI enhances well-being while other standard interventions merely treat depressive symptoms. It found no difference in effectiveness between PPI and other active interventions for improving the well-being of adults experiencing depression. However, due to various limitations, its findings are inconclusive. More studies are needed to accrue the evidence in this area. Nevertheless, the findings suggest PPI’s potential as a viable alternative that has the same outcomes as other psychological interventions.

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Lim, W.L., Tierney, S. The Effectiveness of Positive Psychology Interventions for Promoting Well-being of Adults Experiencing Depression Compared to Other Active Psychological Treatments: A Systematic Review and Meta-analysis. J Happiness Stud 24 , 249–273 (2023). https://doi.org/10.1007/s10902-022-00598-z

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REVIEW article

Fostering positive communities: a scoping review of community-level positive psychology interventions.

• 1 Department of Psychology, Université du Québec à Montréal, Montréal, QC, Canada
• 2 School of Education and Human Development, University of Miami, Coral Gables, FL, United States

Historically, positive psychology research and practice have focused on studying and promoting well-being among individuals. While positive psychology interventions focusing on the well-being of communities and marginalized groups have recently been developed, studies reporting on their nature and characteristics are lacking. The aim of this paper is to examine the nature of community-level positive psychology interventions. It reviews the target populations, intervention modalities, objectives, and desired effects of 25 community-level positive psychology interventions found in 31 studies. This scoping review shows that community-level programs based on positive psychology vary greatly in all these aspects. However, most interventions are aimed at individual-level changes to achieve target group outcomes. Contextual issues such as social conditions, values, and fairness affecting well-being are rarely considered. Discrepancies between community-level positive psychology interventions and community psychology in terms of values and social change are discussed.

Introduction

Positive psychology.

In recent decades, positive psychology has been one of the fastest growing disciplines with regards to well-being research and practice ( Ivtzan et al., 2016 ). Positive psychology evolved in reaction to growing frustrations with the limitations of traditional models of psychology. In contrast to prevalent paradigms, positive psychology focuses on optimal human flourishing ( Seligman and Csikszentmihalyi, 2000 ). Although numerous descriptions of the field can be found, core themes and consistencies have been identified by Linley et al. (2006) . In their view, positive psychology is the scientific study of optimal human functioning. The study of positive psychology operates at three distinct levels: (1) the subjective level, (2) the group, or community level, and (3) the individual level ( Kim et al., 2012 ). Although the subjective level is focused on positive emotions such as well-being, life satisfaction, happiness, optimism and flow, the group level emphasizes civic virtues, social responsibilities, nurturance, altruism, civility, tolerance, work ethics, positive institutions, and other factors that contribute to the development of citizenship and communities ( Boniwell, 2006 ). Finally, the individual level is about ways to become a better person, focusing on human virtues, and character strengths. These virtues are perceived to be core human characteristics valued in most cultures around the world. Character strengths are psychological processes or mechanisms through which a particular virtue is given expression ( Peterson and Seligman, 2004 , p. 13). Twenty-four character strengths compose six virtues: wisdom and knowledge, courage, humanity, justice, temperance, and transcendence.

Positive Psychology Interventions

Initially, positive psychology interventions were defined as “[. . .] treatment methods or intentional activities that aim to cultivate positive feelings, behaviors, or cognitions” ( Sin and Lyubomirsky, 2009 ; p. 468), but not “[. . .] programs, interventions, or treatments aimed at fixing, remedying, or healing something that is pathological or deficient” ( Sin and Lyubomirsky, 2009 ; p. 468). While this initial definition focused on increasing positive elements, researchers have since allowed for a broader view of positive psychology interventions and included effects on negative aspects such as weaknesses, difficulties, and unhappiness ( Schueller and Parks, 2014 ; Worth, 2020 ). Researchers have investigated the possible effects of positive psychology interventions in a wide array of outcomes. Meta-analyses have shown that positive psychology interventions may be effective in fostering character strengths such as gratitude, kindness, humor, and hope ( Carr, 2011 ), and enhancing well-being outcomes ( Sin and Lyubomirsky, 2009 ). They have also reported positive impact of such interventions on the reduction of depressive symptomatology ( Bolier et al., 2013 ). Finally, outcomes such as work-life fit, leadership skills, and work performance have also been studied in school and work settings ( Waters, 2011 ; Meyers et al., 2013 ).

Although the field has historically mostly focused on individual well-being ( Schueller, 2009 ; Di Martino et al., 2018b ), communal and national well-being has also been considered. Seligman has indeed argued that positive psychology aims to create “a psychology of positive human functioning that achieves a scientific understanding and effective interventions to build thriving individuals, families, and communities” ( Seligman, 2002 , p. 7). There is, however, very little information on how to achieve this higher-level well-being. Interestingly, Seligman and Csikszentmihalyi (2000) have given some insight on what group-level positive psychology should aim for:

At the group level, it is about the civic virtues and the institutions that move individuals toward better citizenship: responsibility, nurturance, altruism, civility, moderation, tolerance, and work ethic. (p. 5)

Although positive psychology interventions have largely targeted individual-level traits, such civic virtues have been neglected. Research and practice in fostering citizenship is lacking in positive psychology. Critics have been arguing for years that, while setting out to counterbalance traditional psychology, positive psychology ended up mirroring many of its facets, such as the focus on individual-level factors ( Worth and Smith, 2018 ). Moreover, though programs have been deployed in a wide range of clinical, school, and work settings, community-based interventions are rare. It is evident that the field of positive psychology has focused almost exclusively on individual-level well-being and ignored community, nation and group levels of research, and intervention. There is, however, an interest in the application of positive psychology concepts in groups, as demonstrated by the growing number of studies in workplace and educational settings.

Communities

To study community-level interventions, it is necessary to define what a community is. This is not a trivial task. The term community is widely used but has never received an accepted definition ( Cohen, 1985 ; Trickett and Espino, 2004 ). Chavis and Newbrough (1986) proposed that a sense of community is the organizing concept for the psychological study of community. Warren (1978) has highlighted six different notions: the community as space, as people, as shared values and institutions, as interaction, as a distribution of power and as a social system. McMillan and Chavis's (1986) model describes communities as comprising only four perceptual components: (1) membership (belonging to a community); (2) influence (mattering to the community); (3) integration and fulfillment of needs (the community meeting one's needs); and (4) shared emotional connection (having shared interests/experiences with other community members). These characteristics tend to be associated with strong communities, healthy, and happy individuals (e.g., Davidson and Cotter, 1991 ; Fisher et al., 2002 ; Hystad and Carpiano, 2009 ; Molix and Nichols, 2013 ).

McLeroy et al. (2003) propose that, regarding community-based interventions, communities can either be defined in terms of setting, target of change, resources, or agent. These are in line with the definition of Vaandrager and Kennedy (2017) , in which a community can be understood as a place, an individual and collective identity, a social entity, and a collective action. A participatory public health study, aimed at defining the concept of community, concluded that it was “a group of people with diverse characteristics who are linked by social ties, share common perspectives, and engage in joint action in geographical locations or settings” ( MacQueen et al., 2001 , p. 1929). Ultimately, researchers now seem to privilege a definition of community in terms of geographical area or in terms of relational group with common interests or collective identity (e.g., Netting et al., 2013 ). Based on the existing literature, the definition of community used in this paper is groups of people who share distinctive characteristics associated with common interests or identities . These could be solely geographical, such as residents of the same neighborhood, or sharing joint action, like marginalized and at-risk groups.

Critical Positive Psychology

Some researchers have described an elitist approach to positive psychology, which focuses on WEIRD (Western, Educated, Industrialized, Rich, and Democratic) groups, with little recognition of the influence of social context, and social determinants of health and well-being (e.g., Banicki, 2014 ; Brown et al., 2018 ; Hendriks et al., 2019 ). Although critical psychologists concur with positive psychologists in that people are resilient and have inner strengths to pursue purpose and meaning in life, the former critique the latter for their lack of attention to power differentials and social injustice. Critical psychologists argue that positive and mainstream psychologists neglect the sociopolitical context of people's lives, assuming, wrongly, that anyone with the right skills can overcome any sort of adversity. That is simply incorrect ( Brown et al., 2018 ). Many people succumb to social adversity, and only very few are able to remain psychologically unscathed from the injuries of injustice, oppression, and discrimination ( Prilleltensky, 1994 , 2008 , 2012 ; Prilleltensky and Nelson, 2002 ).

Integrating Positive and Community Psychology

There are similarities but also meaningful differences between positive and community psychology. Both fields share a strength-based approach and reject the definition of mental health as the absence of illness ( Schueller, 2009 ). Practitioners of both fields believe that human beings are capable of self-determination and autonomy. They also share the assumption that it is better to build on assets rather than deficits. But, the similarities pretty much end there. Community psychologists are very concerned with the impact of sociopolitical conditions on personal, relational, organizational, and community well-being; whereas positive psychologists remain largely silent on these issues ( Brown et al., 2018 ; Di Martino et al., 2018b ). In addition, community psychologists are concerned with challenging conditions of injustice, whereas positive psychologists are somewhat indifferent to the societal status quo ( Di Martino et al., 2018b ; Prilleltensky and Prilleltensky, 2021 ). Researchers using a community psychology lens seek to integrate context, social justice, and values in their work ( Di Martino et al., 2018b ). As such, they promote the involvement of disadvantaged communities in creating solutions to their own problems, building supportive structures to help people in need ( Nelson et al., 2014 ). Positive psychologists, in turn, shy away from creating alternative social settings or engaging grassroots organizations. By and large positive psychology remains the province of WEIRD people.

These differences notwithstanding, it is important to understand how positive psychology can contribute to community well-being. This is difficult to ascertain without a review of the field. Perhaps there are positive psychology interventions that can be incorporated into community programs. We cannot provide a clear answer to that question without a thorough examination of the existing evidence. In light of this rationale, the goal of this paper is to critically examine and present a review of the current literature on positive psychology interventions in the context of communities. By mapping out the literature ( Munn et al., 2018 ), we seek to identify the gaps between positive and community psychology. The process followed the methodological framework for scoping reviews proposed by Arksey and O'Malley (2005) and further advanced by Levac et al. (2010) .

The current study aims to provide a description of the potential of positive psychology interventions in communities by presenting the characteristics of interventions implemented within this context. Following Munn et al. (2018) recommendations on evidence synthesis approaches, a scoping review was deemed appropriate to meet these exploratory objectives.

Selection Criteria

As positive psychology interventional outcomes are numerous and used in many fields of practice and research, we solely considered papers explicitly mentioning their intervention being based on positive psychology theory or concepts. Doing so ensured a common theoretical background shared by the interventions reviewed and allowed researchers to be free from making choices to determine what is or is not positive psychology, a challenging process reported in other reviews (e.g., Meyers et al., 2013 ). Based on the work of Hillier-Brown et al. (2014) , community-level interventions were defined as group-based well-being promotion, prevention, education, advice, policy or subsidy interventions, or interventions conducted in a community setting (e.g., churches, community centers, neighborhoods).

Studies were therefore included if they: (1) addressed a community-level intervention; (2); linked the program theory to positive psychology concepts and theory; (3) used measures of individual, group or community-level well-being; (4) were in English. Studies were excluded if the program was: (1) a psychotherapy/counseling intervention; or (2) delivered through an educational or a workplace setting. The rationale behind the exclusion of educational or workplace institutions is that positive psychology interventions in these unique contexts have specific target populations of students or workers, have very distinct objectives linked to their setting, and have been the subject of ample scientific research and publication in the field (see Waters, 2011 ; Meyers et al., 2013 ). Theoretical papers with no empirical investigation were also excluded.

Search Strategy

The databases PubMed and PsycINFO were searched for publications until January 2021. The initial search resulted in 1,252 hits. A number of 73 duplicates were removed for a total of 1,179 publications to review (see Figure 1 ). The search strategy was intentionally broad in order to identify potential interventions which did not mention positive psychology in the abstract but linked its theoretical background in the article (see Table 1 ).

Figure 1 . Flow chart depicting the process of selection of paper for final analysis.

Table 1 . Keywords constituting the syntax entered in the databases.

Abstracts were first scanned by two graduate students (CM and SR); those satisfying the criteria were set aside for full-text reading. The two authors first reviewed the same randomly selected 100 abstracts (around 8%) with a criteria grid they established. They then compared their results. A preliminary inter-rater agreement of 85% was achieved. Differences were discussed and agreements were achieved. The grid used was refined to specify ambiguous elements (such as a shared definition of the concept of community) before each author went to read half of the remaining abstracts. Psychotherapy and counseling interventions were excluded at this stage. Interventions based on positive aging ( Hill, 2005 ; Hill and Mansour, 2008 ), an extension of the positive psychology movement focusing on issues specific to old age ( Hill, 2011 ), were included. However, positive youth development interventions were not included since, although conceptually similar to positive psychology, the field is not considered part of positive psychology (see Lerner, 2005 ). All full articles were read by both CM and SR. Most of the studies that were excluded from our analysis were theoretical in nature and did not involve the empirical investigation of well-being interventions. A total of 27 studies fit the criteria applied. The authors identified 4 additional relevant publications cited in the articles read for a final count of 31 articles included in the review.

Analysis and Synthesis

For each study, interventional target populations, modalities, intervention objectives, desired effects, and reported effectiveness were reviewed. Both reviewers independently extracted data from half of the studies. Theoretical background and participatory methods were also assessed following discussions between them. Interventional outcomes measured were separated in primary and secondary outcomes, when specified. Outcomes reported through the use of a qualitative research method were identified as “emerging” with quotation marks. The numerous desired effects reviewed were grouped into types of well-being following the classification proposed in the I COPPE scale ( Prilleltensky et al., 2015 ). The I COPPE types of well-being were chosen as they include both individual and community well-being, the latter often being omitted or underdeveloped in other well-being conceptualisations. The I COPPE scale consists of overall well-being and six domains of well-being: interpersonal, community, occupational, physical, psychological, and economic (see Table 2 ). While the I COPPE scale itself focuses on classification of subjective well-being, the authors of this article deemed appropriate to use its terminology to group desired effects into meaningful categories of well-being being targeted. Although the inclusion of a distinct spiritual well-being category has been proposed in the past ( Di Martino et al., 2018a ), it can also be considered as part of psychological well-being ( Bozek et al., 2020 ). Due to the lack of consensus and the potential difficulty in separating spiritual well-being to the spirituality character strength, this type of well-being was not included in the current classification.

Table 2 . Classification of well-being outcomes derived from the I COPPE scale.

Well-being was categorized according to the definitions reported in the studies reviewed. When there was no indication of the type of well-being measured, outcomes and instruments were used to categorize well-being variables according to our classification. Finally, character strengths were identified following Peterson and Seligman's definitions ( Peterson and Seligman, 2004 ). This included outcomes not explicitly named as character strengths but comprised in the definitions given by the authors.

In order to document community-level positive psychology interventions' characteristics, we reviewed the year of publication and the country of origin, the program target populations, intervention objectives, outcomes, effectiveness and modalities, theoretical background and participatory methods. With the exception of the year of publication and country of origin of the included studies ( k = 31), the results are grouped and presented by program/intervention ( n = 25).

Description of Included Studies

Table 3 provides a description of included studies ( k = 31) in terms of publication year and country of origin. The majority of included studies were published between 2015 and 2019 (67.7%) whereas another 19.4% were published in the last 2 years. Around 29.0% of studies included were conducted in Hong Kong (China). However, the majority of these studies were conducted by the same group of authors and pertained to the same program series (i.e., FAMILY programs). While another 32.2% of the studies were conducted in the United States, some articles also came from Australia and Italy. A minority of studies were conducted in countries such as Brazil, Canada and Ghana.

Table 3 . Publication year and country of origin of included studies.

Target Population

As seen in Table 4 , programs included in the analyses targeted various populations. A good proportion of programs reviewed targeted older adults (40.0%), which were often residents of nursing homes. Five (20.0%) programs targeted people with different physical conditions, including multiple sclerosis, metabolic syndrome, Parkinson's disease and having received a recent transplant. Some interventions targeted groups with low socioeconomic resources (16.0%), such as individuals living in poor rural communities, homeless female youth, and residents of a low socioeconomic neighborhood. Three related programs (i.e., the Family Kitchen series) targeted families (12.0%). Others targeted what was described as at-risk groups (8.0%), such as female victims of intimate partner violence and mental health service users. Churchgoers and unpaid carers of dependent people made up the target populations of the two remaining programs.

Table 4 . Target population of the programs reviewed ( n = 25).

Intervention Objectives

Supplementary Table 1 provides a summary of the intervention objectives found in studies reviewed. Studies reviewed had numerous intervention objectives, which were mostly geared toward increasing well-being, promoting functioning, or reducing symptomatology. Increasing or promoting well-being was part of the target objectives of 13 programs (52.0%). This included family, mental, social, psychological, positive, and subjective types of well-being. Objectives mentioning health (e.g., increasing health behaviors, promoting mental health, positive mental health, improving health promotion) were part of six (24.0%) interventions. Other, more precise, health-related outcomes such as improving markers of hypothalamic-pituitary-adrenal axis and inflammation were also present. Five (20.0%) programs directly aimed at fostering character strengths and related assets such as resilience and optimism, gratitude, grace, self-forgiveness, and hope. Reducing depressive symptomatology was the target objective of two other programs (8.0%). Other program objectives included happiness (8.0%), quality of life (8.0%), family communication (8.0%) or family relationships (4.0%), physical activity (4.0%), perceived social isolation (4.0%), self-efficacy and morale (4.0%), working memory (4.0%) and psychological capital (4.0%).

Some of the intervention objectives reviewed aimed at countering or alleviating the loss of well-being associated with the condition of certain groups. For example, multiple studies targeting older adults mentioned the reduced happiness and well-being associated with aging (e.g., Ho et al., 2014 ; Bartholomaeus et al., 2019 ). Interventions with low-income populations mostly aimed at promoting well-being outcomes and building strengths to prevent mental health symptomatology associated with economic and living conditions (e.g., Hou et al., 2016 ; Rew et al., 2016 ; Sundar et al., 2016 ). In the context of populations with a physical health condition, positive psychology interventions were mostly used to improve recovery outcomes, and reduce associated psychological distress through increased positive psychology states (e.g., Millstein et al., 2020 ; Amonoo et al., 2021 ). In the case of chronic illness, objectives could also be associated with management and coping, rather than recovery (e.g., Nikrahan et al., 2016 ; Murdoch et al., 2020 ). The program series focusing on families presented clear links between their target population and their objectives of increasing family communication and well-being (e.g., Ho et al., 2016a , b , c ). Finally, the rationale of the grace intervention for a group of churchgoers ( Bufford et al., 2017 ) could not be determined from the information provided in the article.

Intervention Outcomes

Desired effects of interventions were assessed in order to better comprehend how interventions were to achieve their objective. Our review suggests that community-level positive psychology interventions targeted many different outcomes. A total of 200 intervention outcomes were identified ( Supplementary Table 1 ). They were classified according to the type of well-being targeted and 231 types of well-being outcomes were identified, with some outcomes targeting multiple types of well-being. Table 5 provides a summary of programs with at least one target outcome of each well-being category.

Table 5 . Number of programs with at least one target outcome belonging to the different well-being categories ( n = 25).

Psychological well-being was the most widely targeted type of well-being among the different programs. Twenty-one (84.0%) interventions had at least one targeted outcome related to this type of well-being. Anxiety and depression were some of the most frequent target outcomes, along with positive and negative affect, mental health, and resilience. General psychological well-being was also common, though its definition was varied among authors. Nineteen (76.0%) of the programs reviewed targeted at least one overall well-being variable. Life satisfaction, happiness, well-being and quality of life were among the most frequently targeted outcomes. Around half (52.0%) of the interventions targeted at least one character strength. Hope, optimism, gratitude, and spirituality were the character strengths the most often aimed at. Most programs targeting character strengths also targeted well-being outcomes. Some authors conceptualized character strengths as proximal effects of the intervention with distal well-being outcomes resulting from these changes. Others did not do such distinction and considered both types of outcomes at the same level. Twelve (48.0%) programs targeted at least one physical well-being outcome. Thirteen (52.0%) programs also included at least one interpersonal well-being target outcome. Most of these outcomes were related to family relationships, such as family harmony, family communication time, and marital satisfaction, but others were more general (e.g., social connectedness, perceived social isolation, social support). Physical well-being outcomes were varied, but the most common were general physical health, physical quality of life, sleep quality, and self-efficacy in managing a disease. Other outcomes were more precise (e.g., weight, blood pressure, HPA-axis activity markers, substance use). The remaining types of well-being outcomes accounted for a negligible proportion of targeted outcomes, with community well-being and occupational well-being targeted by 8.0% of programs each. Community well-being outcomes included environmental barriers and neighborhood walking resources, and the implementation of a community service project. Occupational well-being outcomes included occupational attainment and the theme of the “engaged life” from a qualitative study. In this case, it was reported that participants (retirees) exhibited elements of confidence, mastery, accomplishment, and involvement in activities following their participation. Finally, no program targeted an economic well-being outcome. Sixteen (8.0%) of all measured outcomes could not fit into these categories, with ten (40.0%) of the programs reviewed targeting an outcome that was not related to character strengths or types of well-being used. Most of these outcomes were related to cognition (e.g., working memory, positive thoughts), behaviors (e.g., coping strategies), or attitudes (e.g., attitudes toward psychology). Spiritual well-being made up 12.5% of non-categorized outcomes.

The evaluation of the effectiveness of interventions is presented in Supplementary Table 2 . The wide variety of research designs, methodologies and statistical analyses used by the different authors has not allowed us to rigorously assess and report on the effectiveness of the different programs. Nevertheless, we have identified trends suggesting significant increases of resilience, happiness and life satisfaction, and significant reductions of anxiety/depression symptomatology following the community-level positive psychology interventions. Effects on character strengths were mixed, whereas effects on physical well-being outcomes were mostly non-significant.

Intervention Modalities

Table 6 presents the intervention modalities of the reviewed programs. In order to attain the desired effects, most studies offered in-person activities (92.0%) whereas two programs were delivered by phone (8.0%) and one of these also gave access to a web-based participant forum (4.0%). The types of activities were similar throughout the programs. Most programs (84.0%) referred to psychoeducational components, such as lectures to define concepts, or didactic books and handouts for educational purposes. A large portion of the programs (80.0%) also focused on skill/strength training, such as breathing exercises, use of personal strengths and coping strategies, or goal setting. Most programs (80.0%) sought to capitalize on their group format by using discussions to report on one's progress since last session, explore one's understanding of themes, or to offer mutual support. Many programs (68.0%) required self-directed exercises or homework to be completed between sessions, with examples ranging from keeping a diary to record positive emotions or events, monitoring physical activity, or completing acts of kindness. A small portion of the programs (16.0%) included art-based activities, such as storytelling, collaborative song writing, or writing of a fairy tale based on one's life. Finally, a portion of programs (24.0%) offered other types of activities, which ranged from group walks to a sermon series, or optional post-training mentoring. Intensity varied considerably across programs, ranging from one 120 min core session with optional booster to a 6-months interactive program of 5 days per week.

Table 6 . Mode of participation and type of activities of positive psychology programs reviewed ( n = 25).

Theoretical Background and Participatory Methods

While the vast majority of the programs were grounded in positive psychology (92.0%), two (8.0%) were based on positive aging. Interestingly, a little more than half of them (60.0%) integrated other theoretical approaches into their interventions. A portion of these multi-theoretical programs (24.0%) included cognitive behavioral therapy techniques. The others (36.0%) incorporated aspects of mindfulness, religious doctrine, holistic health, ecological model, positive youth development, stress management theory, and others.

Most programs reviewed (76.0%) did not include participatory methods. Four of the six programs that included participatory methods were implemented in the context of the FAMILY project and followed a similar structure ( Ho et al., 2014 , 2016a , 2020a ; Zhou et al., 2016 ; Chu et al., 2018 ). In these programs, researchers gathered non-governmental organizations, schools, or social service organizations with whom families were already in contact. The research team offered “train-the-trainers” workshops so that representatives from the organizations could develop and implement brief community-based interventions focused on the targeted concepts. This allowed for the representatives to tailor the intervention to their communities' preferences and needs, while following a general implementation protocol. In the grace intervention ( Bufford et al., 2017 ) the pastors from the two churches collaborated in designing the intervention to ensure that it corresponded to their members' beliefs and practices. Finally, the Hero Lab project ( Sundar et al., 2016 ) is an extensive, 6-month program where initial lessons on positive psychology concepts led youth participants to develop and implement their own project in their neighborhood. The curriculum was also taught by a trained community leader of the same background in regard to faith (Hindu), language, and geography (same community).

The aim of this study was to review the nature of positive psychology interventions taking place in communities. The first finding of this review is that positive psychology interventions implemented in the context of communities mostly aim at increasing well-being, promoting functioning, or reducing symptomatology. These are consistent with a meta-analysis by Sin and Lyubomirsky (2009) , in which the authors reviewed the effects of 51 positive psychology interventions and found support for the hypothesized favorable effect on well-being and for a mitigating effect on depression. There seems to be a consensus that positive psychology interventions do not only increase well-being through multiple theoretical pathways relying on increasing different sets of character strengths, but also improve functioning and decrease negative symptoms (see Worth, 2020 ), sometimes related to illness or aging. Our analysis of objectives and target outcomes showed that authors were mostly interested in distal positive effects of interventions on different types of well-being [reducing depression] rather than proximal effects on character strengths [developing optimism to then reduce depression]. Even though some positive psychology models have been proposed to explain how programs achieve their objectives (e.g., Lyubomirsky and Layous, 2013 ; Raymond et al., 2019 ), current practices make it difficult to develop a comprehensive logic model of positive psychology interventions. It has been argued, for example, that current positive psychology interventions are conceived as cohesive units of activity, which limit their development and evaluation ( Raymond et al., 2019 ; Pawelski, 2020 ). Through our scoping review, we found that researchers present logical connections between intervention objectives and target populations, but that there is a lack of cohesion and reasoning behind activities implemented and some of the target outcomes measured. The analysis of the different constitutive elements and processes involved in an intervention would allow for a better understanding of the specific elements essential for effective positive change in different contexts ( Raymond et al., 2019 ; Pawelski, 2020 ).

Interestingly, most outcomes were considered either overall, physical, interpersonal or psychological well-being, or a character strength. This is somewhat coherent with reviews of positive psychology interventions in organizational settings, in which overall and occupational well-being were targeted (see Meyers et al., 2013 ), and school settings, in which character strengths and psychological well-being were the most targeted (see Waters, 2011 ). What is evident from this review is that, while the interventions reviewed did take place in community settings, only one (Hero Lab) was designed to improve the actual community. The vast majority of interventions took place in community and group settings, but the target of the interventions were individuals. This stems from the fact that the interventions developed are modeled on individual positive psychology interventions consisting of weekly sessions focused on psychoeducation (see Parks and Titova, 2016 ), effectively resulting in a group version of these programs. Communities are treated as passive samples of homogeneous groups of participants with shared characteristics rather than active actors who can participate to better their situation. This is clear in many of the intervention objectives aiming at promoting well-being outcomes and building strengths to prevent mental health symptomatology associated with economic and living conditions rather than working on changing these conditions. There is a meaningful difference between interventions taking place in the community, and programs aimed at improving the community. This review provides clear evidence that most positive psychology interventions address the former and neglect the latter.

It is possible that positive psychologists surmise that communities and organizations will become better if the individuals residing in them become happier and healthier. But this is a problematic assumption. Individual happiness does not necessarily translate into happier organizations and communities. It is true that happier individuals are more tolerant and express more gratitude, creating a gentler psychosocial environment, but this is not the same as creating settings based on fairness and equity. There is abundant evidence that many social structures perpetuate discrimination against people with disabilities, ethnic minorities, and LGBTQ individuals ( Prilleltensky and Nelson, 2002 ; Denison et al., 2020 ; Prilleltensky and Prilleltensky, 2021 ). Some of the barriers to the well-being of these individuals are not interpersonal, but structural. None of the interventions reviewed address power differentials, social injustice, or oppression. In that regard, the critique leveled against positive psychology, that it is similar to mainstream psychology in its individualistic orientation, is borne out by our results ( Brown et al., 2018 ; Di Martino et al., 2018b ).

Having said that, it is possible to build on these positive psychology interventions as a first step in the route toward community well-being. It can be argued that happier and healthier individuals will be better prepared to engage in social change efforts. From this perspective, positive psychology interventions can become a first step in preparing people to collaborate with others in the struggle for social justice. Happier people are usually more productive and collaborative ( Prilleltensky, 2016 ), a great start to coalition building. But if positive psychology interventions begin and end with the individual, and ignore the collective fate of communities, their social and global impact will be limited. Evaluating and even challenging collective norms is especially important in the context of oppressive communities, where minorities are persecuted because of religious or other prejudices ( Sandler, 2007 ). For example, sexual minorities are often discriminated in some countries ( Harper and Schneider, 2003 ). It may be argued that challenging oppressive social norms is beyond the scope of positive psychology, but it is difficult to promote well-being, at any level, without considering power differentials and exclusionary cultural practices ( Prilleltensky, 2001 , 2008 ).

It is also worth noting that very few of the interventions reviewed were participatory and collaborative in nature. They retained the expert model where professionals taught or guided a group of vulnerable individuals in a series of exercises. In community psychology, a participatory approach is valued because it is empowering and it builds citizenship and civic virtues. The interventions described here follow closely the medical model in which an expert imparts advice to a relatively passive recipient, a sharp contrast to community psychology values and ethos. A participatory approach is also particularly favored to recognize and build on existing strengths toward promoting social change ( Israel et al., 2013 ). Although values are often mentioned in reviewed studies through the universal Values In Action model of character strengths ( Peterson and Seligman, 2004 ), the focus is on measuring individual participants' values. This concern does not extend to researchers, as few, if any, of the articles mention the values that frame the study and the context of the intervention. From a community psychology standpoint, we would argue that values of trust, reciprocity, and equity are central in forming positive communities ( Arcidiacono and Di Martino, 2016 ; Di Martino et al., 2018b ).

Many examples of ways to foster positive nations and communities through supportive structures and institutions are discussed in Marujo and Neto (2014) book Positive Nations and Communities. In that book, the focus is on how character strengths and other positive psychology concepts could constructively contribute to building a more just and positive society. Historical and sociopolitical events such as South Africa's Truth and Reconciliation process, the collapse of Portugal's first Republic, Namibia's independence and the European Football Championship are thoroughly explained and discussed through the lens of positive psychology. Their contribution to the cultivation of positive communities is also addressed. The different authors illustrate how citizens' character strengths and well-being may be increased at a macro-level through various means such as festive events ( Proyer et al., 2014 ), social reconciliation processes ( Perstling and Rothmann, 2014 ; Wissing and Temane, 2014 ), legislation ( Perstling and Rothmann, 2014 ), direct democratic participation and local autonomy ( Lopes et al., 2014 ).

On a smaller scale, community interventions based on positive psychology concepts and theory would involve a good proportion of community members and aim to improve social capital among them through collective projects where they can express their gratitude and build on their character strengths and assets. They would target the improvement of the living conditions of these community members (i.e., the social determinants of health) by increasing access to green spaces, places to meet and play, and jobs where they can thrive, for example. Elements such as context, social justice and values should be taken into consideration. Such interventions therefore take time. Indeed, it is impossible to improve community well-being with a few group workshops over a short period of time.

As positive and community psychology share a common goal (i.e., to improve human well-being by gaining understanding of the psychological processes that promote well-being) and if our goal as psychologists is to work toward producing the largest benefit for most individuals ( Kelly, 1971 ), then both community and positive psychologists have much to gain through communication and collaboration ( Schueller, 2009 ). Nonetheless, this scoping review reveals an important knowledge gap that could guide future studies. It is crucial to move the discipline of positive psychology to a higher level of complexity where social change is also considered rather than solely focusing on individual change. With such a perspective, positive psychology has the potential to increase the well-being of more people and contribute to just societies.

This scoping review is, to our knowledge, the first exploration of community-level positive psychology interventions. It provides a worthwhile and detailed summary of intervention background, modalities, and objectives. We believe its contribution to the field to be significant, as it allows for a better comprehension of theory and practice in the field of well-being. In doing so, it strives to move toward a closer collaboration between positive and community psychology.

Limitations

There are a few limitations worth noting about this study. First of all, it included only interventions that were published in English and the interventions reviewed here come from a relatively small number of countries. Second, there are possibly many community change efforts that use positive psychology interventions but do not frame their work that way. For example, Asset Based Community Development has many similarities to some of the interventions described here, especially the promotion of empathy and kindness ( Block, 2009 ; McKnight and Block, 2010 ). Third, well-being was categorized according to the terminology used in the studies reviewed. This created some discrepancies as some authors reported targeting general well-being but used specific subscales of well-being instruments aimed at assessing solely one domain of well-being (e.g., interpersonal). While it was sometimes clear that the instrument used did not assess the variable of interest, it was still categorized according to the author's intent. It is important to keep in mind that the authors of the present study exercised discretion when some outcomes were not adequately described. Finally, the results of the effectiveness assessment we included in this review should be interpreted with precaution, as the current review included a high number of pre-experimental studies lacking a control group. Studies with control groups frequently reported significant main effects but rarely obtained time x group interactions effects. Therefore, a meta-analysis is necessary to rigorously examine the effectiveness of community-level positive psychology interventions.

This scoping review revealed that positive psychology interventions taking place in the community are rich in content and delivery method. However, they focus on the individual level and aim to improve society one person at a time. The many interventions reviewed do not address contextual factors but rather individual-level phenomena. While useful to the individual participating in the program, structural factors that enable or inhibit personal, group, or communal well-being, such as unequal distribution of resources or discrimination, are not addressed by positive psychology interventions.

Author Contributions

This manuscript evolved from a 2019 symposium presentation involving CM, IP and JH. CM conceived the presented idea with supervision from JH. CM and SR performed the literature review and analysis, with input from IP and JH on the analysis and interpretation of the data. CM and SR wrote the manuscript with support from IP and JH. All authors approved the final draft.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

We would like to thank Luc Dargis (Center for Research and Intervention on Suicide, Ethical Issues and End-of-Life Practices) for his help with the search strategy. Funded in part by a Senior Research Scholar grant by the Fonds de recherche du Québec - Société et culture (#282092).

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyg.2021.720793/full#supplementary-material

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Keywords: positive psychology, community psychology, well-being, communities, intervention, scoping review

Citation: Montiel C, Radziszewski S, Prilleltensky I and Houle J (2021) Fostering Positive Communities: A Scoping Review of Community-Level Positive Psychology Interventions. Front. Psychol. 12:720793. doi: 10.3389/fpsyg.2021.720793

Received: 05 June 2021; Accepted: 24 August 2021; Published: 20 September 2021.

Reviewed by:

Copyright © 2021 Montiel, Radziszewski, Prilleltensky and Houle. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Janie Houle, houle.janie@uqam.ca

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

19 Top Positive Psychology Interventions + How to Apply Them

However, this focus began to shift in 1998, when Dr. Martin Seligman and Dr. Mihaly Csikszentmihalyi popularized the concept of positive psychology, an offshoot of clinical psychology that crafted new, positively focused interventions.

According to this new positive psychology paradigm, individuals were encouraged to work with their inner strengths to promote flourishing and the optimal functioning of people, groups, and institutions (Gable & Haidt, 2005).

This new focus represented a dramatic shift from the earlier problem focus that dominated psychological thinking for many years and continues to shape psychological interventions today.

In this article, we’ll explore how positive psychology can serve not only as a remedy for problems but also as a framework to make our work, studies, and personal lives more fulfilling.

Before you continue, we thought you might like to download our three Positive Psychology Exercises for free . These science-based exercises will explore fundamental aspects of positive psychology including strengths, values and self-compassion and will give you the tools to enhance the wellbeing of your clients, students or employees.

This Article Contains:

• What are Positive Psychology Interventions?

Combining Positive Psychology Interventions with Digital Tools

Types of positive psychology interventions (ppis), how do they work, how effective are they, a look at the research article: positive psychology progress: empirical validation of interventions, 5 examples of interventions in use, a list of positive psychology interventions, 4 interventions designed to promote wellbeing, using interventions in the workplace.

• 4 Interventions to Use in a Working Environment

How Can Interventions be Used to Increase Student Happiness?

• 5 Interventions to Use in School

Interventions to Use with Depression

A take-home message, what are positive psychology interventions.

Positive psychology interventions, or PPIs, are a set of scientific tools and strategies that focus on increasing happiness, wellbeing, and positive cognitions and emotions (Keyes, Fredrickson, & Park, 2012).

Existing research shows that over the years, psychologists have focused more on treatment than on prevention (Bolier et al., 2013). Psychotherapy and assessments developed and popularized in the past mostly offered solutions to anomalies like depression, anxiety, stress, panic, and trauma, etc.

There was a little resource available, until the last two decades, on tools that could flourish and promote individual wellbeing, even in the absence of any psychopathological conditions.

Sin and Lyubomirsky (2009) defined PPI as a psychological intervention that primarily focuses on raising positive feelings, positive thoughts, and positive behavior. According to Sin and Lyubomirsky, all positive psychology interventions have two essential components:

• Focusing on enhancing happiness through positive thoughts and emotions
• Sustaining the effects for long-term

Studies have suggested that happiness can be achieved and enhanced through various channels, including sensory awareness, social communication, gratitude practices, and cognitive reformations. As such, all these factors were clustered together in practical techniques called the positive psychology interventions (Parks & Schueller, 2014).

These measures were applied in both clinically distressed and non-distressed populations, and the results were consistent in both the instances (Bolier et al., 2013). By far, the most detailed definition of PPI was proposed by Parks and Biswas-Diener in 2013. According to them, positive psychology interventions are the ones that:

• Have an existing body of research to support its reliability
• Address one or more constructs of positive psychology
• Are scientifically proven and evidence-based
• Benefit us for a lifetime

For instance, some interventions may span several weeks or months and require the guidance of a coach or therapist. Others may comprise just a single activity that a person can choose to complete independently.

Likewise, interventions will differ in whether they encourage individuals to interact with others out in the world or spend some time engaged in quiet meditation or reflection. This article will explore a broad range of interventions that cover all these possibilities.

If you are a coach or therapist, you may find value in applying different combinations of interventions with your clients.

To achieve this, many therapists and coaches assign take-home interventions (or homework) as part of a holistic treatment solution using blended care solutions, such as the platform Quenza .

Tools such as this allow coaches and therapists to assign take-home activities to their clients digitally, which they can then complete on their own smartphone or tablet. These activities can include standardized assessments, reflection exercises, and even audio or video meditations.

Using Quenza, therapists and coaches can even combine a range of simple interventions into a unified pathway for the client to complete over several weeks, with automatically scheduled reminders and deadlines. The therapist and client can then track these deadlines via Quenza’s smartphone or desktop app.

Download 3 Free Positive Psychology Exercises (PDF)

Enhance wellbeing with these free, science-based exercises that draw on the latest insights from positive psychology.

Download 3 Free Positive Psychology Tools Pack (PDF)

By filling out your name and email address below.

In terms of content, a review of the literature reveals that PPIs can be divided into seven categories (Parks & Schueller, 2014).

1. Savoring PPIs

Savoring interventions focus on a particular experience and aim to enhance their effects for maximizing happiness (Peterson, 2006). The core principle of these interventions is to encourage the person to grab every little aspect of experience – physical, sensory, emotional, or social (Kabat-Zinn, 2009).

Due to its emphasis on wholesome perception, the savoring PPIs resemble mindfulness strategies, but they are not entirely alike.

Savoring interventions can be connected to everyday experiences like eating, smelling, or observing, only with a little more orientation and focus to what we are consciously attending to (Bryant, Smart, & King, 2005). Savoring PPIs can be reliably used for treating depression and mood disorders, as they produce happiness and self-satisfaction (Bryant, 2003).

2. Gratitude Interventions

Steve Maraboli said, “ If you want to find happiness, find gratitude ” – which is precisely the target of gratitude-based positive psychology interventions. Gratitude evokes strong feelings of positivity in the person who gives it and the person who receives it (Parks & Schueller, 2014).

Gratitude interventions are categorized into two parts:

• Self-reflective practices, for example, writing a  gratitude journal that we keep to ourselves and use as a tool for self-expression.
• Interactive methods where we actively express our gratitude to others by saying ‘thank you,’ giving small tokens of appreciation, or paying gratitude visits.

No matter what type of practice we follow, gratitude interventions have proven benefits in increasing happiness and satisfaction (Wood, Froh, & Geraghty, 2010). It is such a powerful emotion, that by merely identifying and naming the incidents and the people we would like to thank, we can feel more positive and motivated from the inside (Emmons & McCullough, 2003; Seligman, Steen, Park, & Peterson, 2005).

3. Kindness Boosters

Kindness is a trait all happy people possess. Studies have shown that happiness and kindness go hand in hand and complement each other (Aknin, Dunn, & Norton, 2012).

Positive psychology interventions focusing on compassion can be simple acts like buying someone a small token of love, volunteering for a noble cause, donating something, or helping a stranger in need. Kindness reinforces happiness and positivity.

An example of a related PPI is ‘ prosocial spending ’. The activity includes willingly buying something for someone as a gesture of goodwill. It can be anything like taking your spouse out for a romantic dinner at your favorite place, giving your child the toy he/she has been asking for, or buying a meal to the homeless person you see every day at the bus stop.

It is not about how much money you spend. The goal of kindness activities is to promote happiness through such altruistic and selfless contentment (Howell, Pchelin, & Iyer, 2012).

4. Empathy PPIs

Empathy-oriented PPIs focus on strengthening positive emotions in interpersonal relationships. Healthy social bonds – both at personal and professional fronts are essential for happiness and inner peace. (Diener & Seligman, 2002).

PPIs that promote empathy include activities like self-love meditation and mindfulness practices, where individuals create positive feelings toward themselves and others by being more mindfully connected to the present (Fredrickson, Cohn, Coffey, Pek, & Finkel, 2008).

Empathy-based interventions focus on building relationships through effective communication, broadened perception, and bridging the gap between self and others (Davis et al., 2004).

The core principle behind this is to let us understand others’ perspective and build a strong connection to them (Hodges, Clark, & Myers, 2011).

5. Optimistic Interventions

Optimistic interventions create positive outcomes by setting realistic expectations. An example of an optimistic PPI is the ‘Imagine Yourself’ test where participants are asked to note down where they see themselves in the future.

Evidence suggests that although this may seem to be an easy task, non-directed imagination is a great way for people to understand how positive they are about themselves and others in life (King, 2001).

Another interesting optimism oriented PPI is the Life Summary technique that was administered by Seligman, Rashid, and Parks in 2006. This practice involves assuming that we are happy and prosperous in our lives and writing a summary of our lives based on that assumption.

The review focuses on our strengths, our achievements, and all the fruitful aspects of our lives so far. The method works exceptionally well in gaining insight into where we are going wrong in our daily lives and what we can do to pursue the ideal life we want to.

6. Strength-Building Measures

Strength in positive psychology refers to internal capacities and values (Parks & Biswas-Diener, 2013).

Studies have illustrated that awareness and acknowledgment of power help in reducing symptoms of depression and increases self-contentment (Seligman et al., 2005). As the famous saying goes, “ It is within yourself that you will find the strength you need ,” strength-based PPIs convey a similar message.

They are what psychologists refer to as ‘practical wisdom’ (Schwartz & Sharpe, 2006) and help us use our vitality wisely.

7. Meaning Oriented PPIs

This category of PPIs helps in understanding what is meaningful to us in life and why, and what we can do to achieve the things that matter in life. A person who has clarity of goals and expectations is more likely to feel happier and content (Steger, Kashdan, & Oishi, 2008; Steger, Oishi, & Kashdan, 2009).

If we follow Abraham Maslow’s Theory of Need Hierarchy , the highest level of human needs include self-enhancement and self-esteem, both of which are intertwined with finding the true meaning of life.

Meaning-oriented PPIs include activities like finding meaning in our daily activities, setting realistic goals and employing effective means to achieve them, or just reflecting on our thoughts and emotions (Grant, 2008).

Meaning-oriented PPIs are widely used for treating stress disorders, especially PTSD , where a person needs guidance to find the lost happiness in life and cope with the after-effects of a disaster (Folkman & Moskowitz, 2000).

Today, these interventions are being widely used in fields such as mindfulness , life coaching , relationship counseling, and general psychotherapy as well. The reason why many therapists are replacing their traditional methods with positive psychology intervention and therapies is their investigative quality.

PPIs never rely on symptomatic treatment or a quick relief. Whether treating a psychopathological condition or guiding someone to improve their wellbeing, PPIs target to dig into the root cause of the trouble. Not only that, but it also lets the individual realize the source of his/her problems and enlighten them to embody the changes wholeheartedly.

There are overwhelming pieces of evidence and research findings that suggest the effectiveness and efficacy of positive psychology interventions. However, why they work so well, and how their effects are so deep-rooted is still a vast area of study.

A study conducted on the role of time focus and the effectiveness of PPIs revealed that the two operating factors that contribute to the success of these interventions are – a shift of attention from negative to positive and internalization of positive emotions.

The study was conducted on a sample size of 695, and each of the participants was assigned to either an experimental group or a controlled group. Results showed that subjective feelings of wellbeing significantly improved from pre- to post-intervention, indicating the effectiveness of the PPIs in real life (Wellenzohn, Proyer, & Ruch, 2016).

Positive psychology encompasses both treatment and prevention.

PPIs can be useful for treating depression, anxiety, and stress disorders (Seligman, Rashid, & Parks, 2006). This fact was validated in a study conducted on terminally ill adolescent patients. The purpose of the experiment was to evaluate how positive thinking influenced coping strategies and helped the patients battle their disease with resilience.

In the study, teenager cancer patients were treated with PPIs and showed improved coherence and better stress management . The study was a milestone in the field of positive psychology as besides proving the effectiveness of these interventions; it also showcased the incredible power adolescents possess when it comes to dealing with life-threatening situations or critical health conditions.

Fordyce’s 14 Fundamentals Of Happiness

The effectiveness of positive psychology interventions was also proved by Michael Fordyce (1977, 1983) whose study found that some students in a happiness program derived more happiness because of the fourteen fundamentals of happiness psychology.

Fordyce’s fourteen fundamentals include:

• Being more active and busy
• Spending more time socializing
• Being productive at work
• Being more organized and well-planned
• Reducing worries and negative contemplations
• Fewer expectations, and having more realistic ones
• Practicing positivity through optimistic thinking and reasoning
• Getting more focused and mindfully aware of the present
• Developing and maintaining a healthy personality
• Becoming more empathetic
• Being ourselves at all times
• Replacing negative thoughts with positive ones
• Valuing close relationships
• Thinking about enhancing our happiness

Fordyce’s findings suggested that PPIs improve our state of wellbeing permanently by impacting these fourteen fundamental factors of happiness.

Positive Psychology Progress: Empirical Validation of Interventions was an honest effort by authors Seligman and colleagues (2005) to outline the surprising benefits of the science of happiness and related interventions.

With a host of empirical findings, cross-cultural studies, and books (including DSM), this research paper focuses on how and why PPIs enhance individual happiness.

The roots of positive psychology lie in the pioneering theories of Rogers (1951), Maslow (1962), Erikson (1982), and Jahoda (1958), among many others. From there, researchers like Murray (2000), Vaillant (2000), and Csikszentmihalyi (1975) flourished and extended the scope of the science of happiness to understand how positive emotions and a strong character helps us to lead better lives.

The target of the research was to:

• Review and assess the recent growth in the field of positive psychology
• Explain significant chunks of evidence that promotes PPIs
• Analyze data obtained by surveys and assessments to ascertain the benefits of using these interventions in practical life.

What is CSV?

Character Strengths and Virtues ( CSV ) was a compact handbook of the critical aspects of positive psychology, the active interventions, and bits of evidence promoting happiness as a scientifically attainable state of mind.

Authors Peterson and Seligman (2004) argued that like the DSM or the ICD that encompass almost all aspects of psychopathologies, the CSV encircles all the tidbits of psychological wellbeing.

The research paper on Positive Psychology Progress based its explanations on the six virtues that determine how happy we feel about ourselves and the world.

The study asserted that people derive happiness according to the virtues they follow (Peterson, Park, & Seligman, 2005).

By using assessments like Beck Depression Inventory (BDI), Steen Happiness Index (SHI), and Centre for Epidemiological Studies – Depression Scale (CES-D), the research established the correlation between PPIs and emotional prosperity (Lyubomirsky & Lepper, 1999).

This research also used internet-based faculties to administer and assess the effectiveness of PPIs. Web-based tactics included encouraging participants to download free sheets of positivity inventories and based on the number of registrations per week; an estimation was reached of how curious we are about happiness (Prochaska, DiClemente, Velicer, & Rossi, 1993).

Three interventions were used in this research:

• Placebo Control Exercise – where the respondents wrote about their experiences in a journal every day.
• Gratitude Visits – where the participants wrote letters expressing their thankfulness to someone they had never thanked enough.
• The 3 Good Things Task – where the participants recorded three things in life that make them happy and explain the reason those things make them feel better.

Participants performed these tasks for seven days, and results were evaluated after that. The research work presented by Seligman and Peterson revealed the impact of PPIs on happiness levels and positive responses. Evaluation and statistical analysis showed a marked reduction in the scores of BDI and other depression scales after treating participants with positive psychology interventions.

The authors revealed that we have a natural inclination toward finding out ways to be happy, and PPIs serve this purpose accurately. This article, thus, provides a solid research base that validates the potency of PPI and PPT (Positive Psychology Therapy) in clinical and non-clinical use (Fordyce, 1977, 1983).

Read more about this research .

Although there are many positive psychology interventions we could mention, here is a selection of five to assess.

1. Mindful Interventions

The works of Kabat-Zinn manifested how mindfulness fosters happiness and awareness. As a positive psychology intervention, mindfulness is used in combination with other psychotherapeutic practices, life coaching, and clinical fields. The popular mindfulness-based PPIs include activities like sensory awareness, guided meditation, breath control, and careful observation.

2. Gratitude Exercises

Gratitude turns what we have into enough.

Melody Beattie

Simple gratitude practices like journaling, self-compliments, or sending thank you notes have the power to bring sanctity and authentic happiness. Studies have shown practicing gratitude exercises regularly enhance cognizance and we can derive more pleasure from social relationships (Ryan & Deci, 2001).

3. Objective Assessments

In clinical setups and counseling practices, PPIs are often administered in the form of objective measures like the Mental Health Continuum , Authentic Happiness Inventory, Orientations To Happiness Questionnaire, and Positive Relationships And The Accomplishment Scale.

These tests are mostly conducted under supervision, although some of them are self-evaluative. The scores of these interventions indicate the happiness level of the respondents and indicate how positive interventions impact them.

4. Positive CBT

Cognitive Behavior Therapy ( CBT ) has been there since the advent of psychotherapy and is still a widely used approach for treating many psychological disorders.

Positive CBT is a modification of the classical CBT with a shift in focus from symptom reduction to wellbeing promotion. As an intervention, CBT tries to identify the strengths of the clients rather than identifying and addressing only the manifested problems.

For example, when if a person who has been diagnosed having OCD seeks positive CBT, the therapist, besides working on reducing his obsessive ideations, will also pay equal attention to the positive sides (loving nature, communicative, insightful, etc.) of the person’ character and work on building them.

The principle of CBT is to make the individuals feel better by helping them identify their potencies (Bannink and Jackson, 2011).

5. Active Aging PPI

Active aging, also called positive aging , healthy aging, or optimal aging (Cosco, Prina, Perales, Stephan, & Brayne, 2013) promotes the idea of growing old gracefully.

Much like the famous quote by William Shakespeare “ With mirth and laughter, let old wrinkles come ”, the active aging PPI encourages the older population to accept their aging and live through it with joy.

A study by Vera Roos and Ronette Zaaiman (2017) on active aging revealed that older people who were guided to look into the brighter sides of life and motivated to live the rest of their lives with dignity and joy survived diseases and losses better than others.

Participants of the program, all of who were 60 or above, reported having found the lost meaning of their lives and agreed to practice positivity as a daily habit after that.

The purpose of positive psychology, as announced by Dr. Carol Kauffman (2006), is to “ develop sound theories of optimal functioning and to find empirically supported ways to improve the lives of ordinary and extraordinary people .”

And PPIs are the means to achieve this goal and invite happiness back in our lives. Out of the heaping PPIs that mental health professionals use today, here is a run-down of some of the popular ones that you might find useful.

The Imagined Self Technique

Imagined self is a guided PPI that involves imagining your ideal self and feeling the joy that you would have felt then. Research showed that this exercise acts as a catalyst and provokes people to enact on achieving the life they want to live and derive utmost pleasure like they imagined they would (Sheldon & Lyubomirsky, 2006).

The steps are simple:

• Imagine yourself in the future, living the life you have dreamt of – with all the people you want to share it with.
• Imagine that you achieved everything that you are struggling for now, and you are proud of your achievements.
• Immerse yourself into that imagined self of yours and try to impersonate the happiness and positivity that you think you might feel then.
• Next, ask yourself what you can do to get to that stage in life, and journal your responses.

Positive psychology is secular in all aspects. It gives equal importance to quantitative analyzes like depression and happiness scales, and at the same time also embraces qualitative and self-enhancing practices like yoga , meditation, and mindfulness .

It envelops Buddhist principles of mindfulness and fosters spiritual liberation through yoga postures and meditation (Cerezo, Ortiz-Tallo, Cardenal, & De La Torre-Luque, 2014; Cohn, Pietrucha, Saslow, Hult, & Moskowitz, 2014). Any yoga practice, be that flow meditation, hatha yoga, or other popular methods, renders a relaxing feeling to the mind and the body and is a feasible way to enhance subjective feelings of wellness.

If you are a beginner, here is a snippet of some positivity enhancing yoga techniques that you can follow.

Yoga for self-doubt

Positive energy-boosting yoga

Meditation for positivity

Yoga for self-confidence

Forgiveness Exercise

Holding on to grudges and complaints sucks out our inner peace and prosperity. A beautiful positive psychology intervention that we can follow as a daily practice and imbibe into our personality is the art of forgiving .

This exercise helps us to free ourselves from past resentments and focus on life in a brand new way. And the practice is uber simple.

• Take a piece of paper and name all the people and the incidents of the past that hurt you.
• Beside each name, describe how the negative encounter shattered you. Try to name all the feelings you experienced in that phase (for example – sad, angry, insulted, hopeless, heartbroken, betrayed, hateful, and the like).
• While you are scribbling about all the hurtful encounters, notice how those depressing feelings start coming back to you.
• Now, close your eyes, take two deep breaths and relax for a few seconds.
• Next, imagine each name on the list and in your heart, say ‘ I forgive you ’. Alternatively, if you were at fault, admit it and ask for their forgiveness.
• Notice how this exchange of forgiveness liberates you from the pent up grudges and make you feel empowered from the core.
• Open your eyes and on the paper where you had listed the grievances, write in bolds, FORGIVEN and FREE.

Positive Affirmations

Positive affirmations , like compliments, are “ verbal sunshine ” that brings an immediate sense of pleasure and pride in us. As a PPI, affirmations redirect the mind to focus on the positive sides in ourselves and push ourselves to act positively. They can be simple statements that we say aloud to ourselves every day .

Here are some positive affirmations that we can choose to say to ourselves and let the light enter in our mind, as happiness is a choice that we should make every day.

• I deserve to be happy
• I love my body and my mind deeply
• Today, I will reflect only on the good things in life
• I forgive myself for all past mistakes
• I hold no grudges against anyone
• Whatever has happened, is for the good
• I will live in the present
• From today, I will abandon old habits and embrace new and better ones
• I am grateful for everything I have got so far
• I am a fighter, and I will overcome this
• I will love myself more from today
• Everything is okay and I am at peace with myself

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Although there are a great many interventions dedicated to promoting wellbeing, only four are mentioned below which are well-known and easy to apply.

1. Have-a-Good-Day Exercise

Available from the Positive Psychology Toolkit© , this exercise helps users generate new insights about what makes for a good day and set new goals to strengthen daily wellbeing.

The thinking behind the exercise is that most of us have never deliberately thought about what makes for a good day. However, by stopping to consider how daily events align with our preferences, we can take control of our own happiness.

The activity proceeds in a series of three steps.

First, clients are invited to take two weeks (or a month) to rate their impression of each day on a scale ranging from ‘It was one of the worst days of my life’ (1) to ‘It was one of the best days of my life’ (10). In addition to providing these ratings, clients will keep track of the activities undertaken on those days.

Secondly, clients will respond to a series of open-ended questions exploring the commonalities between the activities that made some days pleasant and some days less pleasant.

Finally, clients will reflect on their previous answers to identify strategies to weave more positive events (and fewer negative ones) into their average day.

If you’re interested, you can find more information on the Have-a-Good-Day exercise by accessing it in the toolkit.

2. Wellness And Wellbeing Workbook

Dr. John Barletta, a well-known Australian Clinical Psychologist, gave a list of some useful PPIs that helps to enhance mental wellbeing and promote happiness.

He uses the worksheet in his practice, as well as in his mentoring sessions, and the exercise includes fifteen prompt-based and self-assessable questions that render immediate clarity to the respondent in terms of his goals, his way of thinking, and what aspects of life can be modified to bring more happiness.

Here is the worksheet .

3. Because I Am Happy – A Happiness Guide

Dr. Scott Bolland and Dr. Bernadette Alizart designed this manual and call it the ‘hidden driver of success’. It comes as a handbook and besides having easy-to-follow PPIs, also contains valuable resources and orientations about the science of happiness. With beautiful pictorial descriptions, relatable references, and point-blank practical tips, this is a valuable resource that we can follow to let happiness in our lives.

Here is the guide .

4. Action For Happiness

The ‘ Action for Happiness ’ worksheet is a set of exercises explicitly promoting and enhancing happiness in our lives. The activities are objective, easy to administer, and is designed in a beautiful way that will grab eyes instantly.

Know more about this manual .

With high rates of clinical depression, poor work-life balance, and stress disorders among professionals all over the world, promoting happiness at work is a sheer necessity now.

According to Shawn Achor, “ Happiness inspires productivity ” at work, and this is the primary driving force behind implementing positive psychology principles at work.

Using PPIs at the workplace promote a healthier and better performance culture. The PPIs that are executed focus on elements like – empathy, meaning, communication, strong character, and self-confidence, with a target on creating job satisfaction, emotional resilience, and healthy competition among employees.

Workplace environment traces how an individual accepts and reacts to the different pros and cons of his work life (Hart & Cooper, 2001).

PPIs in the workplace can be implemented in various forms, such as:

1. Mindfulness Programs at Work

Organizing mindfulness campaigns at the workplace is a growing trend nowadays. These programs focus on building emotional awareness at work, enhancing decision-making power, fostering self-esteem and expressing gratitude.

Example of such training is the Mindfulness At Work program that delivers an array of useful work-related mindful exercises that promote the overall wellbeing of employees and managers.

2. Health Promotion Workshops

We know that “ Happiness is the highest form of health ” – Dalai Lama.

An individual who is struggling with health conditions is less likely to derive pleasure at work. Health promotion in the workplace is beneficial in many ways.

• It promotes awareness of different health issues that may be related to stress and burnout.
• It reduces employee dissatisfaction that leads to unexpected resignations and absconds from work.
• Health awareness curtails health insurance burdens from organizations.
• It ensures a healthy work-life balance among employees.

5 Interventions to Use in a Working Environment

Certain criteria apply in a work environment which forces a strategic selection of interventions, and with that in mind, the following five interventions are proposed for a work environment.

1. The Innovation Time Technique

This is a very popular workplace related PPI, where the participants are encouraged to spend some time brainstorming and pursuing their passion project. The motive of this intervention is to let the individuals enjoy autonomy and invest in something they love to engage in.

Gratitude interventions in all forms are an essential part of PPIs at work. They are used alone or in combination with other interventions with the purpose of enhancing self-contentment and joy among employees.

Some examples of gratitude interventions include:

• Gratitude journaling
• Group gratitude exchange sessions
• Sending gratitude notes
• Self-gratitude exercises
• Guided gratitude meditation

3. Feedback Mechanisms

Feedbacks are a great source of self-improvement. Employees who can accept criticisms and use them to build their professional skills are happier and more satisfied with their jobs than others.

Some ways of incorporating active feedback mechanisms in workplace PPIs are:

• Daily stand-ups where employees and supervisors discuss their progress and share their plans ahead.
• Feedback assessments and surveys administered frequently.
• One on one feedback sessions where both the employee and the supervisor have the freedom to present their opinions and work for a peaceful resolution.

4. Stress Management Exercises

Stress and burnout is an integral part of most professions. Stress management exercises and assessments are a sure shot way to promote the overall physical and mental wellbeing of employees and managers.

Here is an article discussing successful workplace stress management .

5. Self-Management And Emotional Awareness

Designed and used by the organization Quartner and associates, this self-management worksheet is a complete collection of the most useful pieces of information on mental health among employees and workplace happiness. The tips and exercises focus on making the respondents more aware of themselves and identify the stressors at work, thereby providing the scope for replacing their negative emotions and enhance happiness at work.

Learn more about this exercise .

Her research on youth happiness in educational institutions emphasized on the use of positive psychology interventions for fostering student happiness and joy (Suldo, 2016).

The study conducted on student happiness by Lea Waters (2017) is noteworthy here. In her research, she mentioned that 25% of Australian adolescents suffer from mental disorders or distress owing to several factors like family disputes, financial crises, body shaming, and even due to the indirect effects of global warming.

Anxious and distressed children, according to Waters, promoting PPIs in schools by teachers or school counselors can go a long way in helping the kids out of their anxiety, depression, and stress.

Waters’ study (2017) mentioned about PPIs that are immensely effective for enhancing student happiness, some of them being:

• Hope inducing interventions like motivational speeches and one on one coaching sessions. These can help students to look ahead and understand self-worth (Snyder, 1995).
• School-based gratitude interventions like offering gifts and thank you notes. Small expressions of gratitude enhanced life-satisfaction and reduced symptoms of depression among the students (Froh, Sefick, & Emmons, 2008).
• Peace-enhancing positive psychology interventions like mindfulness practices, compassion exercises, and group meditation sessions that helped students discover serenity and release stress (Keegan & Barrere, 2009; Levine, 2009).

4 Interventions to Use in School

Below you will find interventions that can be very empowering in a school environment and have a lasting impact.

1. Character Strengths

Professors Chris Peterson and Martin Seligman named the Character Strengths test as the VIA Classification of the CSV Model, VIA standing for Values in Action. The intervention targets working on these six character strengths:

• Wisdom and knowledge
• Transcendence

(Peterson & Seligman, 2004).

2. Positive Relationships Intervention

This intervention is flexible and straightforward. It involves some structured open-ended questions that students answer. The questions are insightful, thought-provoking, and look something like this:

• Think of a family member you admire and mention why
• Mention one strength that your friend has
• Write about someone who has struggled in life and have come out of it successfully
• For the person you mentioned above, write about the skills that you think helped him fight stress and get his happiness back

3. Bounce Back Resilience Program For Kids

This PPI builds wellbeing by making students more emotionally resilient . It is great for children from kindergarten to middle school standards. The program focus on strategies that help young ones understand and cope with life stressors with more efficacy.

The contents of the program help kids to identify their emotions, bounce back from the sadness and chase their aspirations.

4. The Passport Program

Passport program is used in schools, training, and workshops for adolescents, usually in grades 9-12. The intervention aims to prevent depression among kids by promoting positive education concepts like self-confidence, self-esteem, problem-solving, adjustment, and decision-making.

The curriculum comes in a handy booklet form .

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Expand your arsenal and impact with these 17 Positive Psychology Exercises [PDF] , scientifically designed to promote human flourishing, meaning, and wellbeing.

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Dealing with depression is like “ being colorblind and constantly told about how the colorful the world is ” – Atticus. Positive psychology contributed a lot in helping people understand and fight depression. Here are some PPIs that help people overcome ‘the blues’ and look into the brighter sides of life.

MoodJuice Self-Help Depression Guide

The MoodJuice workbook helps in identifying the symptoms of depression, acknowledging the same, and find ways to overcome it. The exercises involve multiple choice questions related to our thoughts, feelings, and physical symptoms, and the scores indicate the intensity of the depression symptoms.

With lucid pictorial explanations and evidence-backed examples, this workbook is the first choice for many professionals and help-seekers dealing with depression.

Depression Self-Management Toolkit (DSMT)

Created by Angela Gervais and Sheila Olver Szakács, leading professionals in the field of mental health and occupational therapy, the DSMT is a step-by-step guide to fight depression in an organized way.

The toolkit contains brief explanations of the causes and symptoms of depression, followed by standardized tests and assessments to understand the severeness of the present condition. The exercises focus on allied conditions that are related to depression such as physical disorders (hypertension, cardiac dysfunction, sleep disorders, etc.) and stress, and focus on alleviating each negative aspect from its very core.

Antidepressant Skills Workbook

The Antidepressant Skills Workbook (ASW) is a collection of all the essential strategies that help in fighting and overcoming depression.

Authors Dr. Dan Bilsker, Dr. Randy Paterson, have put their years of research into this manual that shows us how by shifting focus from the negative to the positive, we can emerge as happier individuals and combat depression with a very scientific approach.

Happiness is always there around us; we only need to look for it in the right place. As Colette had beautifully put it,

“What a wonderful life I have… I only wish I had realized it sooner”.

Positive psychology is not a resort to fight distress or disappointments. It is a gentle way of reminding us that life isn’t all about adding glories and abandoning pains. If we have the power to love ourselves and others, the determination to work dedicatedly, and the gift of waking up with new energy each day, we already have enough to be thankful for.

We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free .

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this article is really very informative and helpful for me. thank u 🙂

A very valuable article! Thank you so much, helped me in my assignments. I love PositivePsychology.

Hi is it possible to get all the references please? thank you so much, its helping me much on my research!

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Will you provide your citations? Thank you very much.

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Thanks for bringing our attention to this! These references have now been added to the end of the article 🙂

Hello there and thank you for the very helpful post! Can I request you to share a suggested list of books that get into the positive psychology interventions in more detail with examples? Are there books that cover PPIs broadly?

Thank you for your help!

Glad you enjoyed the post! We have an article on 10 must-read positive psychology books, many of which contain interventions. You can find that post here .

Hope this helps!

Can you please provide the reference for Gable and Haidt 2005? It isn’t listed. Thanks

Hi Shannon,

Thanks for bringing this to our attention the reference is as follows (and we’ll get this added to the reference list):

Gable, S. L., & Haidt, J. (2005). What (and why) is positive psychology? Review of General Psychology, 9(2), 103-110.

Could you please provide an article reference for Keyes (2002)? Positive psychology interventions, or PPIs, are a set of scientific tools and strategies that focus on increasing happiness, well-being, and positive cognitions and emotions. (Keyes, 2002)

Hi Natasha, Good spotting! We’ve revised this, and now the citation is Keyes, Fredrickson, & Park 2012 (you can find the book chapter here ). Thank you. – Nicole | Community Manager

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A systematic review of the impact of post-harvest aquatic food processing technology on gender equality and social justice

• Nitya Rao   ORCID: orcid.org/0000-0002-6318-0147 1 ,
• Lee Hooper   ORCID: orcid.org/0000-0002-7904-3331 2 ,
• Heather Gray   ORCID: orcid.org/0009-0002-1933-6332 1 ,
• Natasha Grist 3 ,
• Johanna Forster 1 ,
• Julie Bremner   ORCID: orcid.org/0000-0002-7231-504X 4 , 5 ,
• Ghezal Sabir 6 ,
• Matthew Heaton   ORCID: orcid.org/0000-0001-8087-483X 3 ,
• Nisha Marwaha   ORCID: orcid.org/0000-0001-9822-4085 1 ,
• Sudarshan Thakur   ORCID: orcid.org/0009-0009-5416-4282 7 ,
• Abraham Wanyama   ORCID: orcid.org/0009-0009-9185-459X 1 &
• Liangzi Zhang   ORCID: orcid.org/0000-0002-6231-5783 8  

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Post-harvest practices and technologies are key to reducing global aquatic harvest loss. The lives of post-harvest fisheries workers, over half of them women, are deeply affected by these technologies, but their equity and equality outcomes are poorly understood. This systematic review synthesizes evidence of post-harvest aquatic food processing technology outcomes, showing that persistent inequalities in social structure and norms disadvantage women across a range of technologies, both traditional and improved, especially regarding control over resources. We found that improved technologies bring enhanced productivity and possibly income for workers, yet contracts are often precarious due to pre-existing social inequities. While power and control of resources is more unequal in factory settings, it is not necessarily equal in traditional contexts either, despite offering greater flexibility. More rigorous comparative research, including voices of diverse actors, is key to understanding the impacts of different technologies on gender equality and social justice and inform policymaking.

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Harnessing the diversity of small-scale actors is key to the future of aquatic food systems

Anticipating trade-offs and promoting synergies between small-scale fisheries and aquaculture to improve social, economic, and ecological outcomes

Inland fish and fisheries integral to achieving the Sustainable Development Goals

Data availability.

The data that support the findings of this study are available from the corresponding author upon request. The DOIs of the studies included in the systematic review are presented in Supplementary Table 1 .

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Acknowledgements

This Review received partial funding from the Economic and Social Research Council grant ES/R010404/1 to the project Coastal Transformations and Fisher Wellbeing. We thank our country-level partners S. Velvizhi, M. M. Haque, F. H. Shikha, J. Walakira, A. Atter and K. Addo in India, Bangladesh, Uganda and Ghana for the ground-level insights they have shared with us over the past year and for inputs from E. Allison and S. Haraksingh-Thilsted from WorldFish, which together have motivated this Review.

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This systematic review emerged from discussions between N.R., L.H., J.F., J.B. and N.G. N.R., N.G. and J.F. led the conceptualization and L.H. led the development of the research protocol and study design. Search, screening and extraction was carried out by H.G., G.S., N.M., S.T., M.H., A.W., N.G., J.B. and L.Z., under the guidance of L.H. N.R., L.H., G.S., S.T., N.M., A.W., M.H. and N.G. were responsible for writing sections of the paper based on the preliminary analysis. N.R., N.G., J.F. and J.B. reviewed and edited the paper. M.H., N.M., N.G. and L.H. created the maps, diagrams, figures and tables. H.G. supported referencing. All authors reviewed the final version of the paper.

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Rao, N., Hooper, L., Gray, H. et al. A systematic review of the impact of post-harvest aquatic food processing technology on gender equality and social justice. Nat Food (2024). https://doi.org/10.1038/s43016-024-01034-6

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• Systematic Review
• Open access
• Published: 27 August 2024

Access to oral health care services for children with disabilities: a mixed methods systematic review

• Maram Ali Alwadi 1 , 2 ,
• AlBandary Hassan AlJameel 3 ,
• Sarah R Baker 4 &
• Janine Owens 5  

BMC Oral Health volume  24 , Article number:  1002 ( 2024 ) Cite this article

Metrics details

Children with disabilities experience poorer oral health and frequently have complex needs. The accessibility of oral health care services for children with disabilities is crucial for promoting oral health and overall well-being. This study aimed to systematically review the literature to identify the barriers and facilitators to oral health care services for children with disabilities, and to propose priority research areas for the planning and provision of dental services to meet their needs.

This was a mixed methods systematic review. Multiple databases searched included MEDLINE, Scopus, PsycINFO, EMBASE, and CINAHL. The search strategy included Medical Subject Heading (MeSH) terms related to children, disabilities, and access to oral health. Eligibility criteria focused on studies about children with disabilities, discussing the accessibility of oral health care.

Using Levesque’s framework for access identified barriers such as professional unwillingness, fear of the dentist, cost of treatment, and inadequate dental facilities. Facilitators of access offered insight into strategies for improving access to oral health care for children with disabilities.

There is a positive benefit to using Levesque’s framework of access or other established frameworks to carry out research on oral healthcare access, or implementations of dental public health interventions in order to identify gaps, enhance awareness and promote better oral health practices. The evidence suggests that including people with disabilities in co-developing service provision improves accessibility, alongside using tailored approaches and interventions which promote understanding of the importance of dental care and increases awareness for professionals, caregivers and children with disabilities.

Trial registration

Protocol has been registered online on the PROSPERO database with an ID CRD42023433172 on June 9, 2023.

Peer Review reports

The United Nations Children’s International Emergency Fund (UNICEF) estimates the number of children with disabilities is nearly 240 million [ 1 ]. According to the World Health Organisation (WHO), disability is a comprehensive concept that encompasses impairments, limitations in activities, and restrictions in participation. It is not solely a biological or social construct, but rather emerges from the interplay between health conditions and various environmental and personal factors [ 2 ]. Children with disabilities are at higher risk of poorer health than the general population and the academic evidence highlights the existence of health disparities between children with and without disabilities [ 3 ]. Children with disabilities also experience poorer oral health, with problems ranging from tooth decay and gingivitis to severe periodontal disease [ 4 ]. One longitudinal clinical study has identified that oral health inequity tends to begin in childhood, perpetuating and increasing across the lifecourse, with access to oral health care a key factor associated with better oral health [ 5 ]. Compared to their non-disabled peers, children with disabilities frequently possess complex oral health care needs [ 6 , 7 , 8 , 9 , 10 ]. For example, underlying health conditions may exert an effect on oral health [ 6 , 7 ], sensory and motor impairments may affect their ability to attend routine dental care [ 8 , 9 ] and physical impairments can make oral health care practices, such as toothbrushing, challenging [ 10 ].

Children with and without disabilities need support to access healthcare services, but this can be variable and is dependent on the skills and abilities of caregivers to distinguish between the type and extent of support needed [ 11 , 12 ]. Limited access to oral health care services links to poor oral health outcomes, which may lead to inequalities in oral health for children with disabilities [ 13 , 14 ]. Access, however, is complex, it does not merely mean physically entering a service, it has numerous constructs and potentially modifiable factors such as negative attitudes of professionals, a lack of service provision, or poor geographical distribution of services, amongst others. Then there are fixed factors such as a lack of socio-economic resources in the family, or factors relating to impairment, all of which create barriers to access.

Over the past four decades, various frameworks have been developed to help understand healthcare access dynamics [ 15 , 16 , 17 , 18 , 19 ]. One recent and comprehensive framework is Levesque’s Conceptual Framework for Healthcare Access (Fig. 1 ), published in 2013 after an extensive review of existing literature on healthcare access [ 20 ]. This framework offers a multidimensional perspective on healthcare access within the context of health systems, encompassing approachability, acceptability, availability/accommodation, affordability, and appropriateness. It takes into account socioeconomic determinants and incorporates five corresponding abilities of individuals and populations: to perceive, to seek, to reach, to pay, and to engage, in healthcare access [ 20 ]. Unlike approaches that solely focus on health system failures, Levesque’s framework allows researchers to explore barriers to access resulting from individuals’ abilities to perceive, seek, reach, pay, or engage with healthcare. Access, as defined in this framework, encompasses the opportunity to identify, seek, reach, obtain, or use healthcare services while meeting individual needs access [ 20 ].

Levesque’s conceptual framework for healthcare access

Existing systematic reviews highlights main barriers to dental services for individuals with disabilities, including professional unwillingness to care for their teeth, fear of the dentist, cost of treatment, lack of adaptation of access routes to dental offices or clinics and inadequate health care or dental facilities [ 21 , 22 ]. The work by da Rosa and colleagues [ 22 ] and Krishnan and colleagues [ 21 ] only provides a brief overview because one is restricted to including only cross-sectional studies, and the other refers to barriers faced by caregivers alone. Neither represents a comprehensive analysis of the literature using a broader theoretical framework. Moreover, these reviews [ 21 , 22 ] failed to discuss the facilitators of access to oral health services for people with disabilities. Facilitators of access may resolve barriers to accessing dental services. In contrast, one qualitative study discusses facilitators and barriers, which cross-sectional studies fail to, because the design does not infer cause and effect relationship [ 23 ]. However, this small-scale qualitative study is about adults with disabilities in the UK and not generalizable to other populations. Children with disabilities need support to access dental care, therefore, it is important to identify factors that promote or inhibit access and thereby provide a template of how to increase positive oral health outcomes and attempt to reduce inequalities.

Using Levesque’s Conceptual Framework for Healthcare Access as an a priori framework, this study aimed to (1) systematically review the literature to identify the barriers and facilitators to oral health care services for children with disabilities, and (2) to propose priority research areas for the planning and provision of dental services to meet their needs. The identification of barriers and facilitators to dental care services among children with disabilities could provide guidance for the development of targeted interventions to improve access to oral health care and overall health.

This study is a mixed method systematic review of the evidence on access to oral health care services for children with disabilities, up to 31 st May 2024. Using Participant, Intervention, Comparator and Outcome (PICO) to develop the question, the overarching research question guiding this systematic review was ‘What interventions or designs enable the accessibility of oral health care services for children with disabilities and their parents/carers?’ Other questions are ‘What are the barriers to accessibility of oral health care services for children with disabilities and their parents/carers?’ ‘What increases utilization of oral health care services for children with disabilities and their parents/carers?’

The study follows the updated JBI methodological guidance for conducting a mixed methods systematic review [ 24 ].

Registration of the protocol and PRISMA guidelines

The review adhered to the guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [ 25 ]. Prior to conducting the systematic review, the authors developed a review protocol and registered it with the International Prospective Register of Systematic Reviews PROSPERO on June 9, 2023, under the registration number (CRD42023433172).

Data sources and searches

The search strategy for this systematic review involved searching multiple databases, including MEDLINE, Scopus, PsycINFO, EMBASE, CINAHL and Google Scholar to ensure a comprehensive coverage of relevant studies beyond the databases. Backward or chain searching of references, involves identifying and examining the references or works and enables learning around the development of a topic, whilst identifying experts in the area. Forward searching of references within retrieved records cited in an article after its publication enables finding new theoretical developments in the area and consideration of any other methodologies employed. Second generation forward searching enables the researcher to search for inconsistencies. This process of backward and forward searching of references identified any additional relevant literature for inclusion. To ensure accuracy in the research terminology used, librarians from The University of Sheffield and Manchester University were consulted. Additional file 1. illustrates the complete list of MeSH search terms and the full electronic search strategy.

Eligibility criteria

The studies included in the review included children with disabilities aged 18 years or below. In cases where studies included both adults and children or adolescents, they were considered eligible for inclusion if at least 75% of the participants were children or adolescents, or if separate outcome data were available for this subgroup. This study uses People First language and employs the term children with disabilities, rather than disabled children, although it acknowledges that using the term disabled children implies that society creates barriers because it employs language favored by the social model of disability [ 26 ].

Interventions

Studies discussing access or mentioning dimensions of access to oral health care for children with disabilities were included. Studies of reasonable adjustments and improved access to oral health care for children with disabilities were also included. Oral health studies that solely focused on a particular condition (e.g., Down’s syndrome) or focused solely on the diagnosed oral health condition (e.g., caries or periodontal disease) without any mention of access were excluded. All oral healthcare settings, including dental clinics, hospitals, community health centers, or specialized dental facilities for children with disabilities, were included.

Comparators

Studies with any comparator or no comparator were included. Comparators included intervention or care as usual, as well as studies utilizing alternative approaches for access to oral health care.

The primary outcome assessed in the study was access to oral health care for children with disabilities. If otherwise eligible, for studies that did not report a relevant outcome, attempts were made to contact the authors to determine the outcome. In cases where it was not possible to determine this, the study was listed but the data not fully extracted or included. There is a difference between access to services and effectiveness [ 27 ]. Therefore, papers reporting the ability to physically access, use a service, and/or the standard of service provision were included. Additionally, studies reporting the effectiveness of measures or interventions designed to improve access to the relevant services were reviewed.

Levesque et al.’s model of access [ 20 ] was used as an a priori framework to code how each study measured dimensions of accessibility and corresponding abilities.

Study selection

The study included the following research designs: randomized controlled trials, non-randomized controlled studies, cohort studies, cross-sectional studies, and process evaluations. Mixed method studies and qualitative studies were also included. Systematic and scoping reviews were used to identify primary studies but were not directly included. Studies without primary data, case reports, government reports, guidelines, editorials, commentaries, opinion pieces and conference abstracts, were excluded. Publications in English or Arabic languages, including Arabic due to the Arabic-speaking first and second authors, were included. No countries were excluded from the study. No date restrictions were applied in the search strategy, ensuring a comprehensive inclusion of relevant studies regardless of their publication date. The search was completed up to 31st May 2024.

Inclusion screening

The articles resulting from the search were exported to an Endnote library [ 28 ] and duplicates removed. To ensure consistency, three reviewers (MA, AJ and JO) screened an initial 100 references. Any queries or uncertainties were resolved through discussion. Two reviewers (MA, AJ) then independently assessed the evidence for inclusion using the eligibility criteria at both the title/abstract and full-text screening stages. Disagreements were addressed through discussion and consensus. In cases where consensus was difficult to reach, a third independent researcher (JO) was involved. Studies that did not meet the eligibility criteria during the full-text screening stage were excluded, and reasons for exclusion were recorded (See Fig. 2 ).

PRISMA Flowchart

Extraction of data

Data were tabulated in an Excel sheet, which included author and date, study design, country, sample size, type of disability, outcomes, and barriers and facilitators to access (See Table  1 ).

Two researchers (MA, AJ) utilized Levesque’s five dimensions of accessibility and abilities of persons to interact with the dimensions of accessibility. The table was piloted for 10% of the studies and any discrepancies were resolved through discussion before continuing. A third member of the review team (JO) resolved conflicts of agreement. Table  2 provides detailed analysis of the dimensions of accessibility and ability to interact with the dimensions.

Data synthesis and analysis

This mixed methods systematic review uses questions focusing on different aspects of the same phenomenon. Therefore, the synthesis took a convergent segregated approach, which consisted of conducting separate and independent quantitative and qualitative syntheses but using thematic analysis for both [ 24 ]. Both syntheses employed deductive thematic analysis based on the predefined themes from Levesque et al.’s model of access [ 20 ]. This approach synthesized findings from both qualitative and quantitative studies, offering a comprehensive understanding of access to oral health care for children with disabilities.

Quality and risk of bias assessment strategy

Given the variety of research designs included in this review, the quality of the studies was assessed using the Quality Appraisal for Diverse Studies (QuADS) [ 29 ], and risk of bias was evaluated using appropriate tools for each study design (AXIS Tool for Cross-Sectional Design, and Joanna Briggs Institute critical appraisal tools for both qualitative and case-control studies) [ 30 , 31 , 32 ].

QuADS assesses various important aspects of the studies, such as the underlying theory, defined objectives, appropriateness and rigor of the design, data collection methods, and analytical methods. It consists of 13 evaluative indicators, each rated on a four-point Likert scale ranging from 0 (not at all) to 3 (complete), allowing researchers to determine the extent to which each criterion is met. To ensure consistency, two reviewers (MA, AJ) conducted an initial pilot on 10% of the sample, resolving discrepancies through discussion or with a third reviewer (JO). Table  3 provides detailed scoring of the included studies.

Included studies were also critically appraised by two independent reviewers (MW and AJ) for risk of bias, using tools appropriate for each research design. Cross-sectional studies were evaluated with the “Appraisal Tool for Cross-Sectional Studies (AXIS)” [ 30 ] Table  4 . The standardized Joanna Briggs Institute (JBI) critical appraisal checklists were used for qualitative research [ 32 ] Table  5 , and for case-control studies [ 31 ] Table  6 . Disagreements between reviewers were resolved through discussion or consultation with a third reviewer.

The PRISMA flowchart (Fig. 2 ) illustrates the search results. After screening and applying the eligibility criteria, a total of 36 studies were included in the review.

Study characteristics

The studies incorporated a range of research designs. The majority of these studies (29 out of 36) adopted a cross-sectional study design, representing 80 % of the total papers. The next most common types of studies were qualitative studies, accounting for 11 % of the included papers, followed by case-control comparative studies (2 studies, 6%), and finally, one Mixed Method study (3%). (See Table  1 ).

The studies included 17 different countries (See Fig. 3 ). Among the countries represented in the included studies, the United States (USA) emerged as the most prominent location, contributing 10 studies. These studies encompassed a wide range of sample sizes, varying from 10 participants [ 33 ] to a significantly larger cohort of 12,539 participants [ 34 ].

Total number of papers by country

The studies mentioned a diverse array of disabilities, such as Cerebral Palsy (CP), Autism Spectrum Disorder (ASD), Down Syndrome (DS), Intellectual and/or Developmental Disabilities (IDD), and Physical Disabilities. This broad scope allowed for a comprehensive exploration of the challenges and experiences faced by individuals living with different abilities.

Facilitators and barriers of access to oral health care for children with disabilities

The review identified factors that either facilitated or hindered access to oral healthcare for children with disabilities. These findings were categorized according to Levesque’s healthcare access framework, which organizes them based on dimensions and abilities. Table  1 presents a concise overview of the barriers and facilitators investigated in the included studies, and Table  2 provides a summary of the dimensions and abilities assessed within Levesque’s proposed framework. Included studies addressed barriers, but eight of them did not mention facilitators.

Dimensions of access

Approachability.

The term “approachability” describes a provider’s characteristics that make it possible for people to know they exist and are reachable. This systematic review includes findings from seven studies that highlight both facilitators and barriers related to approachability. Dental outreach programs are identified as effective facilitators for enhancing approachability [ 33 ]. Conversely, the barriers to approachability include a lack of information about dentists competent to treat individuals with disabilities, as well as limited oral health awareness and knowledge of available services [ 35 , 36 , 37 , 38 , 39 , 40 ]. These barriers significantly hindered individuals’ access to and utilization of dental care services, thereby impacting approachability.

Acceptability

Nine of the included studies [ 33 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 ] align with the “acceptability” dimension as defined by Levesque et al.’s conceptual framework [ 20 ]. These studies considered the influence of cultural and societal factors on individuals’ acceptance of specific aspects of dental care access.

The findings from these studies suggest that societal discrimination against individuals with disabilities, characterized by negative attitudes and discriminatory practices, significantly hindered their ability to access dental care [ 33 , 40 ]. Some studies cited the presence of male caregivers and the existence of activity limitations associated with profound autism, as factors involved in barriers for individuals seeking dental care [ 42 ]. Moreover, individuals with complex medical conditions or more urgent healthcare needs may face difficulties in accessing dental care, leading to reduced acceptability of services [ 43 ]. The Acceptability domain failed to identify any facilitators.

Availability/ accommodation

Within the scope of this systematic review, 26 out of the 36 studies included in the analysis contributed insights related to the “availability/accommodation” dimension, specifically addressing barriers and facilitators associated with dental care access [ 14 , 33 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 ]. Barriers linked to availability included the proximity of parking at dental clinics, challenges related to transportation and geographical distance from dental clinics. Other barriers included the absence of reasonable adjustments for accessing dental surgeries, difficulties in locating dentists willing to treat children with specific medical conditions, a shortage of dentists experienced in treating children with intellectual disabilities and prolonged waiting times for appointments or in waiting rooms.

Facilitators enhancing availability included the presence of diverse dental services providing needed care for individuals with disabilities [ 45 , 58 , 59 ], dentists demonstrating willingness to treat children [ 57 ], treatment availability, accessibility, and improved facilities in dental clinics.

Affordability

The issue of affordability appeared in twenty-two of the included studies [ 14 , 33 , 35 , 37 , 38 , 39 , 40 , 41 , 43 , 44 , 46 , 47 , 49 , 50 , 53 , 57 , 58 , 60 , 61 , 62 , 63 , 64 ]. One of the most prevalent barriers hindering children with disabilities from accessing dental care is the prohibitively high cost of dental treatment, compounded by financial constraints and ineligibility for healthcare insurance [ 64 ]. However, reducing the cost of dental treatment can significantly enhance affordability and accessibility for children [ 33 ]. Consequentially, improving access to free dental care services has the potential to increase utilization rates among children with disabilities [ 33 ]. Another valuable facilitator is insurance coverage, for those who can afford it, which further enables access to dental care [ 35 , 37 ].

Appropriateness

Barriers to dental care access for children with disabilities encompass multiple factors. These include the lack of family support [ 33 ]. Negative past experiences with dental services can create anxiety and reluctance [ 33 , 59 ]. A shortage of behavior management skills among general practitioners [ 36 ], discomfort experienced by children during dental procedures [ 37 , 64 ], and the reluctance of some dentists to treat children with disabilities can all affect the appropriateness of care [ 38 , 39 , 50 , 59 ]. Furthermore, communication challenges [ 50 ] and the limited training and awareness of dental professionals about sensory issues in conjunction with the unique traits of children with disabilities can all hinder appropriate care [ 55 ].

Alternatively, facilitators contributing to the appropriateness of dental care access for children with disabilities include the presence of dental staff with positive attitudes [ 33 ] and interaction between the medical and dental systems through integrated care [ 61 ]. Parental positive attitudes and increased awareness of oral health encourages regular dental care, which enhances appropriateness [ 38 , 43 ]. Real-time communication tools [ 51 ], coping strategies, and immersive empathy from the oral health team alleviates anxiety and ensures the acceptance of dental treatment [ 55 ]. Moreover, tailored communication, preparation, and support [ 55 ], along with the expertise of dental professionals who are trained to work with children with special health care needs [ 59 ], all play significant roles in improving the appropriateness of dental care for children with disabilities.

Abilities related to access

Several specific abilities relate to accessing oral healthcare. These include perceive, seek, reach, pay, and engage. Ability to perceive focuses on individuals’ awareness and understanding of available healthcare services. Ability to seek focuses on individuals’ initiative to look for oral healthcare services. Ability to reach refers to the geographical accessibility of oral healthcare facilities. Ability to pay refers to the financial ability to afford oral healthcare services. Ability to engage refers to individuals’ involvement and participation in their own oral healthcare.

Ability to perceive

Twenty-three studies discuss the ability to perceive the importance of dental care [ 14 , 33 , 36 , 37 , 38 , 39 , 40 , 42 , 43 , 44 , 47 , 48 , 53 , 54 , 55 , 56 , 57 , 59 , 60 , 62 , 63 , 64 , 65 , 66 ]. Barriers include a lack of dental awareness among parents regarding oral health and availability of services [ 40 , 56 , 57 , 60 ]. Often, there is little to no awareness of the importance of regular dental visits, contributing to limited perceptions of the necessity of ongoing dental care [ 60 ]. Some caregivers hold the belief that dental care is only essential for specific issues, such as swelling, cracked teeth with pain, or mobile teeth, providing evidence of a restricted understanding of the importance of regular dental visits [ 62 ]. Caregivers frequently perceive their child’s inability to cooperate with dental treatments [ 37 , 47 , 56 ]. They often express concerns about perceived behavioral challenges [ 14 , 33 , 37 , 65 ]. The perception that children are too young for dental appointments [ 53 ] alongside the fear and anxiety children experience regarding dental care [ 14 , 63 ], also present substantial barriers. Parental anxiety [ 63 ] and oral healthcare may have a lower priority compared to other healthcare needs for their child [ 14 ] and contribute to the challenges. Barriers related to children themselves including a lack of complaints expressed by children [ 54 ], children may face difficulties in recognizing dental pain and staff encounter challenges in facilitating communication [ 37 ]. These barriers collectively emphasize the need for the provision of tailored approaches and interventions to improve the perception of the importance of dental care among both caregivers and children with disabilities. Facilitators for enhancing the perception of the need for oral health care encompass various factors. Research suggests that the association between general health issues and parental health behaviors contributes to the recognition of dental care needs [ 37 , 40 , 43 , 58 , 65 ]. For example, children with Down Syndrome (DS) are more likely to seek dental care if they are also receiving speech therapy and ophthalmology services, illustrating a connection between overall health concerns and dental care [ 36 ]. Knowledge of oral health, active participation in oral healthcare programs [ 42 ] and caregiver education [ 44 , 57 , 63 , 64 , 65 , 66 ] also serve as facilitators. Providing parents with coping strategies and techniques tailored to autistic children [ 39 ] improves access to dental care, contributing to the ability to perceive the need for dental care.

Ability to seek

The ability to seek healthcare is influenced by various factors that impact individuals’ autonomy and choice to seek care. Barriers identified in the studies include difficulties and discomfort experienced by children with Autism Spectrum Disorder (ASD) during dental procedures [ 37 ], negative experiences with healthcare professionals [ 41 ], limited access to routine oral care among children belonging to ethnic minorities [ 49 ], perceived child IQ and behavioral issues [ 65 ]. These barriers hinder the ability to seek healthcare, resulting in disparities in accessing appropriate care.

On the other hand, facilitators identified include children’s age and parents’ educational attainment [ 63 ]. Older children may possess a better understanding and ability to express their healthcare needs, which facilitates their ability to seek care. Higher levels of education appear to facilitate parent acquisition of knowledge about healthcare options, enabling them to make informed decisions and actively seek necessary care for their children [ 63 , 64 ].

Ability to reach

“Ability to Reach,” in 17 included studies, identify barriers primarily focusing on personal mobility and transportation availability, affecting individuals’ ability to physically reach healthcare providers [ 14 , 33 , 35 , 37 , 39 , 40 , 42 , 44 , 47 , 50 , 53 , 56 , 57 , 58 , 62 , 63 , 64 ]. These barriers encompass issues such as proximity of parking at clinics [ 33 ], lack of transportation [ 35 , 50 ], difficulties in transportation [ 37 , 47 , 53 , 62 , 64 ], long travel distances, waiting times, challenges related to wheelchair access [ 40 ], limited access due to the scarcity of nearby dentists, insufficient time for visits, high travel costs, and time-consuming appointments. No studies mentioned facilitators of access.

Ability to pay

Fifteen studies explore barriers and facilitators related to the dimension of “ability to pay”, for dental care access for children with disabilities [ 33 , 34 , 35 , 40 , 41 , 44 , 48 , 52 , 53 , 56 , 57 , 61 , 62 , 66 , 67 ]. Barriers related to financial constraints, low income [ 34 , 40 , 56 , 62 ], and a lack of insurance coverage [ 41 , 48 , 53 , 67 ]. Facilitators within this domain were private insurance coverage, free treatment options [ 33 ], and insurance programs designed to provide dental care for vulnerable populations [ 35 , 48 , 67 ].

Ability to engage

Twenty-five studies discuss the ability to engage [ 33 , 36 , 37 , 38 , 40 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 56 , 57 , 58 , 59 , 64 , 65 , 66 ], identifying numerous barriers to engaging children with disabilities in dental care. These obstacles range from children’s hesitance towards dental treatment [ 45 ] to difficulties experienced by children with ASD during dental procedures [ 37 ] and their perceived lack of cooperation during dental care [ 47 ]. Challenging behaviors, emerged from the fear of the dentist [ 52 ], which further compounds barriers. The anxiety of dental staff and concerns about uncooperative behavior or fear-related issues also hinder engagement [ 38 ]. Effective communication has been identified as a pivotal facilitator for dental care utilization [ 57 ]. Some studies suggest that having a milder degree of intellectual disability as a facilitator of access [ 50 ], suggesting that children with less severe intellectual disabilities may find it easier to engage with dental care compared to those with more significant communication impairments. Alternatively, dental staff may find it easier to communicate. It also suggests that dental professionals lack effective communication skills. These multifaceted barriers underscore the need for tailored strategies to enhance engagement among children with disabilities in accessing dental care.

Quality and risk of bias assessment

All included papers in this systematic review were rated for quality using the QuADS criteria [ 29 ]. (See Table  3 ). These revealed a mixed picture regarding the methodological rigor of the studies. Scores ranged from 36 to 85%, indicating varying levels of quality. While some studies demonstrated explicit theoretical or conceptual frameworks, clear descriptions of the research setting, and appropriate sampling methods, others lacked these crucial elements. The choice and justification of data collection tools and analytic methods varied, with some studies offering detailed justification and explanation, whilst others offered rudimentary accounts. Furthermore, few studies actively engaged stakeholders in the research design [ 14 , 33 , 52 ], for example, in one study stakeholders were actively involved [ 33 ], they formed an expert review committee and conducted pilot interviews with five caregivers to gather feedback on the clarity and language of the interview guide. The collaborative efforts resulted in a refined and validated Malay version of the guide, evidencing the active role of stakeholders in shaping the research design and ensuring methodological quality. Whereas only a limited number of studies provided comprehensive discussions of their strengths and limitations [ 36 , 42 , 44 , 48 , 59 , 60 , 63 , 67 ].

The study used the appraisal tool for cross-sectional studies (AXIS), detailed in Table  4 , revealed several key findings across different study designs. Out of the 29 cross-sectional studies, 11 were medium and 18 high quality, demonstrating a low risk of bias. Studies commonly demonstrated clarity in aims and appropriate study design for the study question. Many of them used sampling frame that makes the results fairly generalizable (such as registries), however, many lacked justifications for sample size as well as detailed statistical methods, as seen in AlHammad et al. [ 45 ]. And almost all of them were unclear in terms of dealing with non-responders, raising concern about potential difference between responders and non-responders which might affect how representative the sample is. It worth mentioning that each study used different measures/ questions of access to oral health care services, but all used relevant ways to assess the research aim. Qualitative studies, like those by Abduludin et al. [ 33 ] and Parry et al. [ 55 ], they were generally well-aligned between methodologies and research questions but often failed to address the influence of researchers and their theoretical positioning on their study findings. Case-control studies, exemplified by Du et al. [ 38 ] and Mansoor et al. [ 54 ], demonstrated good comparability and valid outcome measurements but frequently did not explicitly state strategies to address confounding factors. Across all designs, ethical standards were typically well-maintained, though improvements in sample justification, detailed data analysis, and addressing researcher influence were needed.

This study systematically reviewed barriers and facilitators of oral healthcare access for children with disabilities, adopting Levesque et al.’s healthcare model of access as an a priori framework [ 20 ]. Among the 36 studies included, the majority (31 out of 36) explored specific dimensions and abilities of access to healthcare, though not all aspects were equally covered.

The main findings of the review were that only 7 out of 36 studies mentioned or indicated approachability, which ignores the contribution of healthcare professionals in the oral healthcare encounter, 9 out of 36 studies mentioned acceptability, whilst 12 out of 36 mentioned appropriateness, therefore failing to consider issues such as reasonable adjustments. In contrast, 24 out of 36 studies focused on the patient’s ability to engage. This discrepancy suggests that there may be a prevailing attitude that children with disabilities are the “problem” rather than recognizing that the barriers lie within the oral healthcare system itself. This observation aligns with the medical model of care, which views individuals as the issue, as opposed to the social model of disability [ 26 ], which focuses on the barriers imposed by the healthcare system. Moreover, children with profound autism and complex medical conditions face additional obstacles in accessing dental care, highlighting the need for a social model of disability to address systemic challenges.

Accessing dental care for carers of children with disabilities presents a range of barriers. Limited oral health awareness and knowledge of available services [ 35 , 36 , 37 , 38 , 39 , 40 ], coupled with a lack of information and awareness about dentists willing to treat children with disabilities [ 40 ], all contribute to difficulties in finding suitable dental providers. There is a shortage of dentists experienced in treating children with intellectual disabilities, plus a lack of dentists’ knowledge and training in providing care further restricts access to appropriate dental care [ 48 , 49 ]. The difficulties faced by dentists while treating children with disabilities may stem from inadequate education and training in this area. Research argues that special care dentistry is often omitted from dental curricula [ 68 , 69 ], leaving future dentists ill-prepared to interact with and treat individuals with disabilities. This highlights the need for comprehensive dental education programs that prepare undergraduate dental students to effectively interact with and treat children with disabilities [ 70 ]. Increasing the exposure of dental students to patients with disabilities has proven to enhance their skills, foster positive attitudes, and boost their competence and confidence [ 71 , 72 ]. Therefore, targeted training for future dental professionals can play a crucial role in supporting the inclusion of children with disabilities in oral health initiatives and reducing oral health disparities.

While the included studies shed light on barriers to dental care access, the discussion around facilitators lacks consistency. Dental outreach programs [ 33 ], parental education [ 57 , 63 , 65 ], and collaboration between medical and dental systems [ 61 ] have significant potential to improve oral health outcomes and accessibility for children with disabilities. Ensuring parents and caregivers have appropriate and accessible information and health education appears vital to overcoming barriers [ 73 ]. Collaborative and multidisciplinary care emphasizes the benefits of continuity of care when patients interact with multiple services [ 36 ].

The systematic review has demonstrated that there is a broad international interest in the area, with evidence from a number of countries. This diversity enhances the generalizability of the findings, offering a comprehensive view that spans multiple research environments and contexts. The prominent contributions from countries like the United States and India highlight regions with strong research infrastructure and focus. Meanwhile, the involvement of other nations underscores the universal relevance and collaborative nature of the research field, reflecting a global commitment to advancing knowledge.

Strengths and limitations

The strength of this systematic review lies in its use of a conceptual framework to synthesize findings on oral healthcare access, mapping barriers and facilitators to provider and user characteristics, dimensions and abilities. Employing a systematic and comprehensive approach in collecting and identifying papers minimized the likelihood of missing relevant studies. The methodology used establishes a transparent link between the primary research and the conclusions drawn in this review. The inclusion of multiple reviewers in all study stages also served to reduce selection bias. However, using an existing framework poses a potential limitation, risking oversight of other relevant themes. To address this concern, all authors independently conducted searches for additional themes that could enhance the framework but failed to identify any. Only five papers included in this review adopted a theoretical model of access as a framework to guide the research. Two studies [ 33 , 44 ] used Levesque’s framework, another [ 52 ] employed the Institution of Medicine model of healthcare utilization, one [ 53 ] applied the Behavioral Model of Health Services Use, finally, one [ 40 ] utilized the Modified Penchansky’s 5A classification. While the remaining 31 included papers did not incorporate a theoretical model of access. Nevertheless, the adoption of Levesque’s framework allowed consolidation of the barriers and facilitators to dental care access from multiple studies, enabling categorization into the five dimensions and five abilities, resulting in a more comprehensive overview.

Implications and future recommendations

This mixed methods systematic review contributes to understanding the complex landscape of oral healthcare access for children with disabilities. Applying Levesque et al.’s [ 20 ] theoretical framework provides a comprehensive understanding of barriers and facilitators affecting access. Identified barriers have implications for policymakers, healthcare providers, and educational institutions. This includes collaboration between dental and other medical systems, which appears vital to ensure coordinated and comprehensive care and assists in ensuring the provision of multidisciplinary care. Reducing the cost of dental treatment, insurance coverage, and/or providing access to free or subsidized dental care services for individuals with disabilities are crucial facilitators. Exposing dental professionals to individuals with disabilities during learning years and improving their communications skills with different patients’ group can enhance their skills, confidence, and willingness to provide care to individuals with disabilities. Adopting the social model of disability shifts the focus from individuals as the “problem” to systemic barriers, demanding attention.

Future recommendations include studies employing rigorous methodologies and involving various stakeholders such as children, parents/guardians, dental professionals, and policymakers. Utilizing comprehensive and up-to-date frameworks like Levesque’s conceptual framework enables a deeper exploration of the barriers and facilitators associated with oral health care services for children with disabilities. Addressing barriers and leveraging facilitators, provides the foundations for equitable access to oral healthcare for children with disabilities. This aims to improve their oral health outcomes and contribute to their overall well-being and quality of life.

Conclusions

This review highlights the diverse and global interest in addressing oral healthcare access for children with disabilities, reflecting a collaborative and universal commitment to improving health outcomes. The findings underscore the need for systemic changes, including better training for dental professionals, increased collaboration across healthcare systems, and policy adjustments to reduce financial barriers. By focusing on both barriers and facilitators, this review provides a pathway towards more equitable and effective oral healthcare services for children with disabilities.

Availability of data and materials

All data analyzed during this study are included in this manuscript.

Abbreviations

The United Nations Children’s International Emergency Fund

Quality Appraisal for Diverse Studies

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Appraisal Tool for Cross-Sectional Studies

The standardized Joanna Briggs Institute

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The authors extend their appreciation to the King Salman Center For Disability Research for funding this work through Research Group no KSRG-2023-171.

The research was funded by the King Salman Center For Disability Research through Research Group no KSRG-2023-171.

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Alwadi, M.A., AlJameel, A.H., Baker, S.R. et al. Access to oral health care services for children with disabilities: a mixed methods systematic review. BMC Oral Health 24 , 1002 (2024). https://doi.org/10.1186/s12903-024-04767-9

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Popoiu, T.-A.; Pîrvu, C.-A.; Popoiu, C.-M.; Iacob, E.R.; Talpai, T.; Voinea, A.; Albu, R.-S.; Tãban, S.; Bãlãnoiu, L.-M.; Pantea, S. Gastrointestinal Stromal Tumors (GISTs) in Pediatric Patients: A Case Report and Literature Review. Children 2024 , 11 , 1040. https://doi.org/10.3390/children11091040

Popoiu T-A, Pîrvu C-A, Popoiu C-M, Iacob ER, Talpai T, Voinea A, Albu R-S, Tãban S, Bãlãnoiu L-M, Pantea S. Gastrointestinal Stromal Tumors (GISTs) in Pediatric Patients: A Case Report and Literature Review. Children . 2024; 11(9):1040. https://doi.org/10.3390/children11091040

Popoiu, Tudor-Alexandru, Cãtãlin-Alexandru Pîrvu, Cãlin-Marius Popoiu, Emil Radu Iacob, Tamas Talpai, Amalia Voinea, Rãzvan-Sorin Albu, Sorina Tãban, Larisa-Mihaela Bãlãnoiu, and Stelian Pantea. 2024. "Gastrointestinal Stromal Tumors (GISTs) in Pediatric Patients: A Case Report and Literature Review" Children 11, no. 9: 1040. https://doi.org/10.3390/children11091040

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• v.15(1); 2023 Jan

Healthcare Workers' Well-Being: A Systematic Review of Positive Psychology Interventions

Alexandra p townsley.

1 Psychology, Rice University, Houston, USA

Jenny Li-Wang

2 English, Rice University, Houston, USA

Rajani Katta

3 Internal Medicine, Baylor College of Medicine, Houston, USA

4 Dermatology, The University of Texas Health Science Center at Houston (UTHealth Houston), Houston, USA

Given persistent occupational stressors and multiple challenges in the delivery of healthcare, there is an increased focus on the well-being of healthcare workers. Responding to these challenges will require a multipronged approach, focusing on system level, organization, and individual actions. Positive psychology interventions (PPIs) represent a promising area for individual action. This systematic review indicates that PPI, delivered via many methods, holds promise for improving the well-being of healthcare workers, although there is a clear need for additional randomized controlled trials utilizing defined and standardized outcome measures. In this review, the most commonly evaluated PPIs were mindfulness-based or gratitude-based interventions. These were delivered via different methods, with many administered in the workplace and commonly in the form of courses ranging from two days to eight weeks. Researchers documented measurable improvements in multiple studied outcomes, noting reductions in symptoms of depression, anxiety, burnout, and stress. Some interventions increased well-being, job and life satisfaction, self-compassion, relaxation, and resilience. Most studies emphasized that these are simple, accessible, low-cost interventions. Limitations included some nonrandomized or quasi-experimental designs, alongside generally small sample sizes and varying methods of intervention delivery. Another concern is the lack of standardized outcome assessments and long-term follow-up data. As almost all studies included were performed before the pandemic, further research will be required post-pandemic. Overall, however, PPI shows promise as one arm of a multipronged approach to improving the well-being of healthcare workers.

Introduction and background

With a renewed focus on the well-being of healthcare workers in the face of increased occupational stressors [ 1 ], there is increased interest in the development of effective and easily implemented strategies that improve healthcare workers' well-being. The detrimental effects of the COVID-19 pandemic on the mental health and well-being of the healthcare workforce have been well-documented and extensively studied. Although elevated levels of depression, anxiety, and burnout among physicians and other healthcare workers are by no means a new phenomenon, the unprecedented conditions of the pandemic have greatly exacerbated this well-established phenomenon [ 2 ]. Heavy patient loads, long and irregular work hours, an unprecedented fall in employment early in the pandemic [ 2 , 3 ], and patient mistrust [ 4 ] have contributed to increased anxiety, depression, insomnia, and low self-efficacy [ 5 ]. A range of interventions will be needed to support healthcare workers' well-being in light of these stressors. A review of previously employed interventions may provide some guidance.

Responding to these challenges and improving the well-being of healthcare workers will require a multipronged approach, focusing on system-level, organizational, and individual actions. Promising interventions that may be employed by individual workers have been described in the positive psychology literature. Positive psychology is a field of study established by Seligman et al. in the early 2000s, with a focus on studying “positive emotions, positive character traits, and enabling institutions” [ 6 ]. Positive psychology interventions (PPIs) have been found to increase well-being and decrease depression from baseline in the general population with continued adherence, with effectiveness varying across interventions [ 6 ]. Multiple PPIs have been described; in this paper, we focus on those studied specifically in healthcare workers.

One frequently investigated PPI in the general population is mindfulness-based interventions (MBIs). Mindfulness in itself is a state of active awareness and attention directed at the present moment and includes nonjudgmentally attending to one’s current feelings and experiences [ 7 ]. Examples of MBIs include mindful movement programs, mindfulness meditation, and the body scan, in which awareness is focused on different areas of the body to progressively relax [ 7 ]. Another commonly studied PPI is the Three Good Things  or Three Blessings  intervention. In this exercise, participants write down three good things that happened in their day as well as the causes for them [ 8 ]. Multiple trials have also studied combinations of interventions, including PPI and other interventions that are based on positive psychology concepts and research.

The purpose of this study is to systematically review studies that evaluated PPI in healthcare workers to determine if PPIs help improve healthcare workers' well-being.

This study employed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) to organize and describe the findings of this systematic review (Figure ​ (Figure1). 1 ). A literature search was performed from August to October 2022.

Search Strategy

A primary literature search was conducted using Google Scholar, PubMed, and PsycInfo databases. The search terms used were “positive psychology interventions,” “positive psychology in healthcare,” and “positive psychology in medicine.” All articles meeting the search criteria with full-text articles available were selected. A total of 36 articles were selected initially: 10 from PubMed, 2 from PsycInfo, and 19 from Google Scholar. Reviewing the references of included studies identified five additional articles.

Figure credits: Alexandra P. Townsley.

PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analysis

Inclusion criteria were as follows: studies must be based on positive psychology concepts, written in English, and with full-text availability. The studies must employ a positive psychology-based intervention, with currently employed healthcare workers as subjects, and outcome measures must be defined, measured, and related to well-being. Studies that did not meet inclusion criteria included review articles and editorials, those with patients as subjects, and those measuring treatment outcomes, communication, or patient satisfaction as outcome measures. Of the initial 36 articles, 22 were excluded for not meeting inclusion criteria, resulting in 14 articles being analyzed and included in this study. Data from included studies included the study title, intervention and duration, number and occupation of participants, outcomes, and study design. The information extracted from the included articles is summarized in Table ​ Table1 1 .

Adapted from [ 9 - 22 ].

RCT, randomized controlled trial; MBSR, mindfulness-based stress reduction; RN, registered nurse; 3GT, Three Good Things; PPT, positive psychology tool; CMA, certified medical assistant; HCW, healthcare worker

This systematic review indicates that PPIs, delivered via a number of methods, hold promise for improving the well-being of healthcare workers, although there is a clear need for additional RCTs utilizing clear and standardized outcome measures.

PPIs, evaluated in multiple populations, have demonstrated measurable reductions in stress, anxiety, and burnout as well as improvements in job satisfaction and subjective well-being. These interventions have also produced physical benefits, including decreased inflammatory biomarkers and cortisol levels, as well as documented cognitive benefits, including increased working memory and decreased distractibility [ 23 ].

These benefits are of particular relevance to healthcare workers. The occupational challenges inherent in healthcare result in significant cognitive, emotional, and physical demands. Even under normal working conditions, physicians and other healthcare workers daily encounter stressful situations and intense cognitive and emotional demands. Cognitive demands include, among many others, the need to make critical healthcare decisions as well as the need to focus attention in the face of frequent distractions and interruptions. The emotional demands are significant as well, including caring for and communicating with distressed patients as well as self-regulation and emotion work in taxing situations [ 8 ].

These challenges were intensified during the COVID-19 pandemic, and although the pandemic has begun to wane, the mental health effects persist. Studies have consistently shown an increase in anxiety, depression, and stress experienced by healthcare workers throughout the pandemic. One study found that 98.5% of physicians experienced moderate-to-severe stress levels during the pandemic, with 90.5% reporting varying levels of anxiety and 94% reporting mild-to-severe depression [ 24 ].

Under these conditions, the development and evaluation of interventions focused on improving the well-being of healthcare workers are of high priority. Improving physicians' well-being requires a multipronged approach that incorporates system-level, organizational, and individual actions [ 1 ]. Interventions based on positive psychology principles may be useful at the individual level and offer a potentially low-cost, safe, and effective tool when used alongside systemic and organizational improvements.

The positive psychology literature has established the efficacy of PPI in the general population via multiple research studies, including multiple randomized controlled trials (RCTs) [ 6 ]. Most of these PPIs were designed specifically to be completed easily at home to increase one’s sense of subjective well-being. There are seven basic categories of PPI: savoring, gratitude, kindness, empathy, optimism, strengths, and meaning. Savoring is based on the idea that if one directs their focus and attention to a positive event, one can prolong the positive emotions that result from that intervention; mindfulness-based interventions often fall into this category [ 25 ]. Gratitude interventions are designed to focus attention on the people and things that create positive events and feelings in one’s life. Interventions based on empathy seek to strengthen social connections, which have been shown as essential for happiness. Optimism activities emphasize thinking about the future and creating positive expectations. Activities based on strengths encourage one to identify character strengths and then use them in new ways. Finally, meaning-based interventions are focused on understanding and engaging with one’s meaning in life [ 6 ].

In this literature review, the most commonly evaluated PPI in healthcare workers was based on mindfulness or gratitude. Of the 14 studies, 8 were mindfulness-based, with a focus on either stress reduction or self-care. Mindfulness-based interventions have been studied extensively in different populations. These may be administered via different methods and have demonstrated effectiveness in multiple RCTs. One RCT found that an eight-week mindfulness-based stress reduction (MBSR) intervention was well-tolerated and of comparable effectiveness as the medication escitalopram in the treatment of generalized anxiety disorder [ 26 ].

Interventions in this study ranged from MBSR to mindful self-care interventions and demonstrated diverse modes of administration. Most were administered in the workplace in the form of courses ranging from two days to eight weeks. Two trials designed a combined intervention focusing on resilience and mindfulness. These interventions sought to increase well-being by teaching coping strategies for stressors and adversity (resilience), along with mindfulness. Another study combined mindfulness education with general positive psychology education, while one study used a resilience-based intervention.

Mindfulness-based interventions have grown in popularity as research has demonstrated benefits. Healthcare workers in qualitative studies have described benefits for themselves, their colleagues, and their patients, such as nurses who reported improvements in coping with workplace stress and developing feelings of inner calm [ 27 ].

In the studies reviewed here, researchers documented measurable improvements among a host of studied outcomes, including stress, burnout, exhaustion, depression, anxiety, and others. Research continues into potential mechanisms of action for these benefits. Some may be mediated via physiological mechanisms. Breathwork, included in many mindfulness meditation practices, includes slow breathing practices. This practice increases links between the parasympathetic and central nervous systems, which produces higher order cognitive control and mental flexibility [ 28 ]. During times of physiological stress response activation, therefore, the neural centers responsible for interpreting and reducing stress responses are also activated, resulting in stress reduction.

Mindfulness has also demonstrated anti-inflammatory benefits. One negative effect of stress is the upregulation of inflammatory biomarkers. Mindfulness meditation may counteract the negative inflammatory effects of stress by changing gene expression over time to downregulate inflammatory proteins [ 28 ]. Mindfulness-based interventions also exert effects on stress responses via neural pathways in the brain. Structural MRIs have demonstrated that these practices are associated with diminished activity in the amygdala in response to stress-inducing stimuli while in “mindful states as well as in a resting state” [ 29 ]. In other words, while experiencing stress, the emotion and fear center of the brain is less aroused in those who practice mindfulness than in those who do not.

Mindfulness may also prove beneficial via impacts on cognitive load. Any task performed by a healthcare worker inherently involves a degree of cognitive resources and effort, known as intrinsic cognitive load [ 30 ]. Extraneous cognitive load is not inherent to the task but may be impacted by inefficiencies in the system. Mindfulness can reduce cognitive load by increasing working memory capacity while simultaneously reducing the occurrence of distracting thoughts [ 23 ]. Even brief mindfulness meditation sessions have been shown to improve executive attention [ 31 ]. Reducing the overall cognitive load may prove beneficial to the well-being of healthcare workers [ 32 ].

Four of the interventions in this review were gratitude-based. Some of these interventions were traditional “three good things” interventions. In these interventions, participants are asked to write about three good things that they are grateful for each day, along with causal explanations of how they brought about those things or events. Other gratitude interventions were focused on keeping gratitude journals or diaries. Gratitude is generally thought to be effective for increasing well-being and reducing symptoms of anxiety and depression owing to a more positive view of the self and a focus on the positive emotions and events created by gratitude [ 33 ]. Gratitude interventions that prompt the expression of gratitude to others may also increase well-being through strengthened relationships [ 33 ].

In this review, overall, PPIs were effective at reducing symptoms of depression, anxiety, burnout, and stress while increasing well-being, job, and life satisfaction, self-compassion, relaxation, and resilience. Most studies emphasized that these PPI are simple, accessible, low-cost interventions that can be employed either at home or in the workplace. Therefore, they could potentially be easily replicated and deployed in other institutions.

Despite these promising results, several questions and limitations remain. Several studies used nonrandomized or quasi-experimental designs rather than the gold-standard RCT. The RCTs are limited by generally small sample sizes, as well as varying methods of intervention delivery. In addition, of the 14 studies in this review, only three provided information on participants' dropout rates, and reasons for dropout were not addressed. In these three studies, dropout rates were 0% [ 15 ], 12% [ 13 ], and 44% [ 10 ]. Another concern is the lack of standardized outcome assessments, limiting the comparison of the effectiveness of different administration methods. Additionally, long-term follow-up data is lacking, with the longest follow-up period here at three months. Long-term longitudinal data will be required to determine the duration of benefits, as well as to evaluate optimal intervals of intervention delivery. Another limitation of this systematic review is that the studies identified here, with one exception, all administered PPI before the onset of the pandemic. Publication bias should also be considered; although all studies in this review demonstrated positive outcomes, studies with negative outcomes may be less likely to be published.

In terms of future directions, high-quality RCTs that utilize clear and standardized outcome measures are needed to determine best practices for designing and delivering effective interventions. The development of standardized outcome measures should be a priority, and special focus should be paid to how healthcare workers can implement such practices in the face of challenging schedules. Future trials should also identify best practices for identifying individuals who are interested and who may benefit as well as closely monitoring rates and reasons for participants' dropout. Another question that remains is the effectiveness and feasibility of interventions implemented in the workplace setting versus interventions employed exclusively at home. Finally, another area for future study will be the assessment of the efficacy of PPI administered post-pandemic.

Conclusions

In this systematic review of studies investigating the use of PPIs in healthcare workers, promising results were noted. Despite the current limitations, the studies reviewed here show promise as one arm of a multipronged approach to improving the well-being of healthcare workers. More research is needed into standardizing outcome measures and comparing different modes and methods of delivering these interventions.

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The authors have declared that no competing interests exist.