This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.
In Taiwan, which has one of the most rapidly aging populations in the world, it is becoming increasingly critical to promote successful aging strategies that are effective, easily usable, and acceptable to institutionalized older adults. Although many practitioners and professionals have explored aromatherapy and identified its psychological benefits, the effectiveness of combining 3-dimensional (3D) virtual reality and hands-on aromatherapy remains unknown.
A quasi-experimental trial was designed to evaluate the effectiveness of this combination in lowering perceived stress and promoting happiness, sleep quality, meditation experience, and life satisfaction among institutionalized older adults in Taiwan.
A total of 60 institutionalized elderly participants either received the combined intervention or were in a control group. Weekly 2-hour sessions were implemented over 9 weeks. The outcome variables were happiness, perceived stress, sleep quality, meditation experience, and life satisfaction, which were assessed at baseline and after the intervention.
Generalized estimating equation (GEE) analyses indicated that the experimental group showed significant post-intervention improvements in terms of scores for happiness, perceived stress, sleep quality, meditation experience, and life satisfaction (n=48; all
This is the first trial to explore the effectiveness of a combination of 3D virtual reality and hands-on aromatherapy in improving older adults’ psychological health. The results are promising for the promotion of psychological health in institutionalized older adults.
ClinicalTrials.gov NCT04324216; https://clinicaltrials.gov/ct2/show/NCT04324216.
Scientific and technological advancements and the resulting improvements in human living environments and medical treatments have resulted in a gradual aging of the human population. In 2016, the global average life expectancy at birth was 72.0 years. It is estimated that by 2050, the proportion of adults over 60 will double [
However, previous studies showed poor psychological health among older residents of Taiwanese nursing homes. For example, the prevalence rates of unhappiness, poor sleep, depression, and anxiety among surveyed residents of Taiwanese nursing homes were 50% [
Aromatherapy, also known as essential oil therapy, is a complementary treatment that uses ingredients from different parts of plants, such as leaves, flowers, and seeds, to yield aromatic essential oils using different extraction techniques. Aromatherapy is widely used clinically in the treatment of chronic pain, anxiety, depression, cognitive disorders, insomnia, and stress-related diseases [
A descriptive exploratory study investigating the prevalence and type of complementary and alternative medicine (CAM) use among older Taiwanese patients with depression found that 69.6% of participants reported using at least one form of CAM, and 20.9% used aromatherapy in the past 12 months; in addition, 6.8% and 7.3% reported using aromatherapy for treating their depression weekly and daily, respectively [
Another study in Taiwan indicated that among 3 alternative remedies, aroma massage was a more effective intervention than cognitive stimulation therapy and reminiscence therapy in alleviating the agitated behavior and depressive symptoms of residents with dementia in 10 nursing homes [
Three-dimensional (3D) virtual reality (VR) involves participants using devices, such as helmets and joysticks, to observe a virtual scene. This approach allows situational teaching; it provides an interactive learning environment that is not limited by time and space, thereby increasing convenience in learning and allowing real-time practice. The 3D virtual world provides rich interactions to maintain users’ attention in environments similar to the real world. Furthermore, 3D VR is interactive, integrated, and imaginative, and can be used to aid learning [
The combination of 3D VR and hands-on aromatherapy allows for a powerful learning experience and facilitates the construction of a 3D space for aromatherapy products. There is some evidence that VR can help increase learners’ interest and motivation and effectively support knowledge transfer, since the learning process can be settled within an experiential framework [
Until now, it has been difficult to provide elderly persons with an opportunity to practice before performing hands-on aromatherapy activities. However, the emergence of 3D VR can solve this problem. If 3D VR can be successfully used, the difficulties elderly participants experience when engaging in hands-on aromatherapy activities might be overcome. Another advantage of a 3D VR educational activity is that it can prevent the waste of materials in hands-on activities for institutionalized older adults.
Because older adults’ hearing and hand-eye coordination are relatively poor compared with young and middle-aged adults, they are more likely to struggle with the hands-on aromatherapy activities, based on our practical experience. Thus, older adults need more workers and material support for successful engagement in hands-on activities. If the elements of 3D VR technology can be integrated into the aromatherapy intervention and reduce the burden of human and material resources, it will significantly contribute to the CAM literature. It is reasonable to conduct research that explores 2 effective strategies combined to improve the psychological health of institutionalized older adults. Therefore, the purpose of the present study was to explore the effectiveness of a combined program of 3D VR and hands-on aromatherapy in improving institutionalized older adults’ psychological health.
We used a quasi-experimental design, which was found to be a common study design in aromatherapy studies in a meta-analysis [
A total of 30 participants were recruited from each nursing home through posters and advertisements, and the total number of participants was 60. According to Kirk [
The elderly participants in this study were all older than 65 years. The selection criteria included having the ability to understand verbal instructions, provide simple responses, and operate a joystick freely with at least one hand. The exclusion criteria were (1) a history of severe psychiatric conditions, (2) dementia, (3) significant visual or hearing impairment, (4) marked upper motor difficulties that could affect the participant’s ability to participate in the study, and (5) currently suffering from severe illnesses (eg, stroke, Parkinson disease).
The study received approval from the Research Ethics Review Committee of National Taiwan Normal University (201903HM012). We confirm that we have obtained verbal permission to use images of the individuals included in this article.
A flowchart outlining participant enrollment and assessments is provided in
After potential participants were identified, we provided an orientation session with 3D VR and hands-on aromatherapy to test the feasibility and acceptance of the combination program. Participants indicated their appreciation of this arrangement and reported that the 3D VR program could help them perform better in the subsequent hands-on aromatherapy activities. The research team members collected their baseline data in a quiet room provided by the nursing home.
During the implementation period of the intervention, a medical professional, staff of the nursing home, and an aromatherapy professional were available to ensure the safety of the participants. The counterparts in the control group did not receive the aromatherapy intervention at the same time.
Flowchart of participant enrollment and assessment. 3D: 3-dimensional. VR: virtual reality.
The intervention consisted of 2-hour weekly sessions over 9 weeks. The first week involved ice-breaking activities, during which the participants were taught to wear 3D VR helmets and operate VR handles with familiar VR scenes so that the participants could practice multiple times to avoid dizziness. The contents of the program are shown in
The research team developed the combination program, involving aromatherapy, long-term care, elderly health promotion, and health education professionals. The characteristics of the 3D VR and hands-on aromatherapy program were appropriate for the psychological status of the elderly participants. The final versions of each session (see
The participants in the experimental group were divided into multiple groups with a facilitator to enhance individual engagement and solve the problems associated with operating the 3D VR device. A staff member of the nursing home asked participants to record a 7-day log of daily usage of the hands-on aromatherapy product, seen in
Examples of the 3D VR and hands-on aromatherapy program. 3D: 3-dimensional. VR: virtual reality.
Sociodemographic variables assessed at baseline included age, gender, and educational level. The psychological outcome variables are presented below.
The Oxford Happiness Inventory was used to measure happiness. It consists of 29 items and assesses the following 7 concepts: positive cognition, social commitment, positive affect, sense of control, physical fitness, satisfaction with self, and mental alertness [
The Perceived Stress Scale is a self-reported scale that measures the degree of stress experienced by an individual over the last month. In comparison with life events, it has shown good predictive validity for various health outcomes [
The Pittsburgh Sleep Quality Index [
A shortened version of the 10-item Experiences During Meditation (EOM-DM) scale [
The life satisfaction scale for older adults developed by the Health Promotion Administration of the Ministry of Health and Welfare [
Descriptive analyses were conducted for demographic and outcome variables. A 2-tailed
After the first-round analysis, we found that all outcome variables showed significant improvements (
The participants’ average age was 83.03 (SD 7.6) years and 81.92 (SD 9.0) years in the experimental and control group, respectively. There were no statistically significant differences in participants’ education levels and gender distribution between the experimental and control groups. Hotelling
Group differences in the patterns of change over time are shown in
The majority of participants were adults aged 80 years and older (n=20 and n=15 in the experimental and control group, respectively), and the GEE analysis yielded a significant group time interaction for the 5 outcome variables. The experimental group showed an improvement in the scores for happiness (GEE coefficient=12.43;
Changes in happiness, perceived stress, sleep quality, meditation, and life satisfaction between experimental and control groups.
Results of generalized estimating equation analyses.
|
GEEa coefficient | SE | 95% Wald CI | Wald chi-square ( |
||||
|
|
|
Lower | Upper |
|
|
||
|
|
|
|
|
|
|
||
|
Group (experimental group)b | –1.17 | 2.74 | –6.53 | 4.20 | 0.2 (1) | .67 | |
|
Time (posttest)c | –2.50 | 0.79 | –4.05 | –0.95 | 9.9 (1) | .002 | |
|
Group (experimental group) × time (posttest)d | 12.58 | 1.84 | 8.98 | 16.19 | 46.8 (1) | <.001 | |
|
|
|
|
|
|
|||
|
Group (experimental group)b | –3.96 | 2.38 | –8.63 | 0.72 | 2.8 (1) | .10 | |
|
Time (posttest)c | –0.25 | 0.73 | –1.68 | 1.18 | 0.1 (1) | .73 | |
|
Group (experimental group) × time (posttest)d | 12.00 | 1.72 | 8.64 | 15.36 | 48.9 (1) | <.001 | |
|
|
|
|
|
|
|
||
|
Group (experimental group)b | –0.72 | 0.97 | –2.63 | 1.18 | .6 (1) | .46 | |
|
Time (posttest)c | 0.64 | 0.39 | –0.12 | 1.40 | 2.7 (1) | .10 | |
|
Group (experimental group) × time (posttest)d | –4.72 | 0.65 | –5.99 | –3.45 | 53.2 (1) | <.001 | |
|
|
|
|
|
|
|
||
|
Group (experimental group)b | –3.01 | 1.50 | –5.94 | –0.07 | 4.0 (1) | .04 | |
|
Time (posttest)c | –1.79 | 0.59 | –2.95 | –0.63 | 9.2 (1) | .002 | |
|
Group (experimental group) × time (posttest)d | 11.92 | 1.33 | 9.32 | 14.52 | 80.7 (1) | <.001 | |
|
|
|
|
|
|
|
||
|
Group (experimental group)b | 0.25 | 0.59 | –0.90 | 1.40 | 0.2 (1) | .67 | |
|
Time (posttest)c | 0.08 | 0.17 | –0.24 | 0.41 | 0.3 (1) | .62 | |
|
Group (experimental group) × time (posttest)d | 1.79 | 0.42 | 0.97 | 2.61 | 18.4 (1) | <.001 |
aGEE: generalized estimating equation.
bReference group (group): control group.
cReference group (time): pretest.
dReference group (group time): control group pretest.
To our best knowledge, this is the first interventional study to use 3D VR and hands-on aromatherapy in a combined program and verify its effects on the psychological health of institutionalized older adults through an appropriate research method. A unique feature of this study is that the participating older adults engaged in hands-on preparation of aromatherapy products that they were then encouraged to use daily over the subsequent week. In addition, a research team member tracked the participants’ 7-day use of each aromatherapy product over 8 weeks. We believe that these strategies successfully increased the intervention intensity compared with previous studies, which often lacked a supporting strategy and tracking design for the daily use of hands-on aromatherapy products [
We used the outcome variable of happiness instead of depression, which was used in another study [
Moreover, we found an alleviating effect of aromatherapy on perceived stress, which is in line with a previous study [
Regarding sleep, a meta-analysis of 12 studies showed that the use of aromatherapy was effective in improving sleep quality [
Smith and Kyle [
However, in a systematic review and meta-analysis [
Regarding meditation, a previous study examining 20 adults’ meditation processes demonstrated electroencephalogram changes with lavender inhalation, which presented as an increase in fast theta and slow alpha activities in the frontal area during meditation [
Aromatherapy has been found to be effective in improving psychological symptoms as well as overall quality of life, especially among patients with cancer [
A Cochrane systematic review [
First, because the program integrated 3D VR and hands-on aromatherapy, the contribution of either approach cannot be easily isolated using the current study design, as they are linked to each other. To validate the effectiveness of the 2 approaches separately, additional studies should be conducted using controlled trials with enough power. Second, we cannot comment on the longer-term effectiveness (ie, 12 months postintervention) of our program. Additional follow-up is needed to determine how the described intervention program affects older adults’ psychological health beyond 12 months after completion of the intervention. Third, the intervention might not apply to frail older adults, but it indicated that if more support is provided, such as the involvement of family members and caregivers, frail older adults could also participate in the program.
The results are important for supporting similar future programs for institutionalized older adults. Our program adopted an innovative approach to improve psychological health among institutionalized older adults. A combination of 3D VR and hands-on aromatherapy activities provides more learning opportunities compared with other aromatherapy interventions. In addition, tracking the participants’ use of each aromatherapy product for 7-day periods over 8 weeks was a successful approach, as it extended the connection with participants outside the classroom and contributed to the significant improvements in psychological health among participants. In the future, the effectiveness of this approach may be scientifically verified by comparing 2 groups: those who receive only the aromatherapy program and those who receive the aromatherapy program and a monitoring approach such as usage logs.
To ensure early interventions for institutionalized older adults who experience psychological distress and to prevent the development of multiple psychological disorders, researchers and staff in nursing homes should target the older adults who are still in a state of psychological subhealth. Providing one-on-one interventions in nursing homes may not always be feasible or affordable. To reduce the burden of instruction, learning contents could be delivered through a 3D VR program, which can provide a safe and supportive learning environment and empower researchers and practitioners to play a vital role in solving problems, leading discussions, facilitating older adults’ learning, and providing feedback. During the intervention period, 2 staff members at the experimental nursing home were interested in participating in the delivery of the intervention and wished to act as facilitators to encourage participants to engage in the interventional activities. This indicates that our program can easily be implemented in nursing homes. Since the implementation is not complicated, nursing home staff receiving short-term training can deliver the program successfully to promote residents’ psychological health.
Combination of 3D VR and hands-on aromatherapy: Program components.
CONSORT-eHEALTH checklist (V 1.6.1).
3-dimensional
complementary and alternative medicine
Experiences During Meditation
generalized estimating equation
virtual reality
We thank all the study participants for their time and commitment. This article was subsidized by the National Taiwan Normal University, Taiwan, Republic of China.
None declared.