1. Between Access, Understanding and Effective Use of Health Instructions
For health professionals it seems therapeutic to use humor, as it serves to improve the relationship with their patient and for themselves. Vilaythong et al.  refer that individuals who displayed high humor production also had lower mood disturbances (p. 80).
Sharing humor contributes to feelings of togetherness, closeness, and friendship, promotes positive communication in the following ways: prevention, perception, perspective .
Among the cognitive aspects, the presentation of life in a humorous way can help patients to accept certain difficult situations in a more existential way, accepting the dilemmas of life .
In the social field, the use of humor by patients can strengthen interpersonal skills, social confidence and reduce social phobia .
For Damásio , learning depends on emotion (p. 351) and all emotions use the body as a theater (p. 73), so the use of emotions, where humor fits, causes reactions in individuals, what the author  identifies it as an “extended awareness” of feeling and perceiving the other” (p. 277) and in this sense, when emotions are generated, understanding can be facilitated. Rutherford  says that humor can be used to increase social interest, reduce feelings of inferiority.
Currently, there is an understanding of the wide range of direct and indirect effects that humor and laughter have on perceptions, attitudes, judgments and emotions, which potentially benefit the individual’s physical and psychological state Gelkopf .
Individuals need motivations to be able to memorize the sometimes very technical guidelines that health requires. Functional and interactive health literacy  requires the patient to know how to understand health instructions, how to read and understand package inserts, prescriptions, medication, dosages, signage, among other elements that are part of the health universe. We also know that about 50% of patients both in the United States of America  and in Europe  have low health literacy, that is, they have difficulties in accessing, processing, understanding and using health information and navigating the health system itself .
The CDC  states the following: Data from the 2003 National Assessment of Adult Literacy (NAAL), and the 2012 Program for the International Assessment of Adult Competencies (PIAAC) show that adult literacy skills change relatively little over time. According to the PIAAC, only 12% percent of adults showed the highest proficiency level on literacy tasks, and even less, 9%, showed proficient numeracy skills. These results are the same as a decade earlier when the NAAL demonstrated that only 12% of adults have proficient health literacy skills.
CDC  affirms that an adult at the below basic literacy level might be able to locate and circle the date of a medical appointment on a hospital appointment. An adult at the proficient level might find the information required to define a medical term by searching through a document.
On the other hand, most health relationships are interpersonal relationships, where the patient and the health professional face each other in the complexity of what is required by this health relationship.
In healthcare, the data show that health professionals manage the therapeutic relationship and have more power in controlling and managing the results and we find in the literature several studies that prove it   .
Health professional have technical competences and the “healing power”  and, on the other hand, patients have different levels of understanding .
The definition of therapeutic relationship is approached as a collaborative and interpersonal relationship between professional and patient, in each space, time and context, aimed at enhancing and empowering the person, to understand and be able to adhere, if possible, autonomously, to health instructions, in order to achieve the best health outcomes, namely in general healthcare, rehabilitation, prevention and health promotion.
Depending on the degree of involvement of each actor, there are three possible models of the doctor-patient relationship: 1) the activity-passivity, in which the physician is active and the patient is passive, 2) the guidance-co-operation, in which the physician is active, and the patient follows the doctor’s advice, and 3) the mutual participation, in which the doctor guides the patient, helping him/her .
2. How Humor Is Seen and Feel: The Biological, Psychological and Social Perspective
The search in the PUBMED database (Ap.1) resulted in the selection of a set of 20 articles in the areas of medicine and nursing, psychiatry and psychology, individual, mental and behavioral health. The option was to identify articles that had the word humor in the title. We wanted to evaluate how the authors position themselves in the various dimensions of biopsychosocial health and well-being.
In 1993, Martin, Kuiper, Olinger and Dance  revealed that greater levels of humor are associated with a more positive self-concept, self-esteem, and standards for self-worth evaluation, a more positive and self-protective cognitive appraisals facing stress, and greater positive affect in response to both positive and negative life events.
Rotton , a year earlier, in 1992 did an investigation 88 living entertainers, 43 deceased comedians and 91 literary humorists and several types of data on 803 entertainers and writers. Analyzes provided little support for the idea that individuals with a well-developed sense of humor live longer than serious writers and other entertainers. The question that arises is that if a life of “artist” continues and is stressful, will it not allow the positive effects of humor as well-being?
Franzini  in a perspective of physical and psychological effects, states that, in addition to the potential effects on clients, therapeutic humor might have the positive side effect in minimizing the burnout of professionals. Empirical studies have shown that contentment and joy accelerate the recovery from the cardiovascular effects of negative emotions .
Lefcourt  in 5 consecutive stressful tasks, with 60 male and 49 female undergraduates, observed, using systolic and diastolic blood pressure as an indication of cardiovascular reactivity, that humor is a potential stress moderator. The Coping Humor Scale, with prediction of blood pressure interacted with sex. Females who were higher in coping humor exhibited lower systolic blood pressure, but reverse in males, who scored high on the coping humor scale exhibited higher systolic blood pressure than males scoring low on that scale. Also, Martin and Dobbin  investigate whether sense of humor moderates’ immunosuppressive effects of stress. These authors find that subjects with low scores on the humor scales revealed a stronger negative relationship between hassles and S-IgA than did those with high humor scores. The authors use four scales to assess different aspects of the sense of humor.
In this biological and cognitive line, Ganz and Jacobs  reveal that humor is a mental state, spanning aspects of cognition, emotion, behavior, and communication.
Training skills centered on humor in a mental health service, can improve better rehabilitation outcomes, a sense of humor for schizophrenia patients in rehabilitation stage  and can be an effective coping strategy .
Still regarding psychological aspects, the sense of humor was associated with a better quality of life and with fewer symptoms of depression and anxiety although they considered that the induction of laughter could lead to lung hyperinflation .
Martin  recalls that humor is part and is essentially a social phenomenon. Therefore, in a person with sense of humor is social functions and daily performances are at high level . Jeludar et al  further state that, the more the sense of humor a person have, the more the social performances will increase.
According Martin , humor enhances social support and contributes to psychological health and resistance to stress, and individuals with a greater sense of humor are thought to be more socially competent.
Stieger  emphasize that humor is an essential part of our life to cope with stressful life events and associated with a higher ability to reduce angry feelings and external expression of anger .
Martin  validates the Humor Styles Questionnaire (HSQ), used in research on humor and psychological behaviors, which assesses 4 dimensions of individual differences in the uses of humor. Humor can be used for the individuals themselves, the “I”, for their self-improvement, or else to improve relationships with others (affiliate), also delimiting aggressive humor, in which individual improvement is obtained at the expense of others, or, conversely, defeatist humor, in which use only serves to improve the condition of others.
These authors  find that individuals who are high on affiliative humor tend to facilitate relationships.
Heintz  used this scale HSQ (2003) and elaborates a study of 45 daily humor behaviors and their relationship with the 5 great personality traits and with subjective well-being to better understand the behavior of individuals’ mood. Hierarchically assessing mood behaviors (N = 123) that correlate with emotional stability, extraversion, less pleasantness and culture/openness. The dimensions of cheerful, fun and self-directed humor behaviors were associated with subjective well-being, even when personality and humor styles were controlled. For this author , investigating these humor behaviors is beneficial for future research and applications of individual mood differences.
A summary of what was presented can be read in Table 1.
3. Results and Discussion
3.1. Qualitative Study with Health Professionals: Humor in the Right Dose
To assess the perception of health professionals about the use of communication competences, among which, the use of humor in the therapeutic relationship, a qualitative study was developed with 88 health professionals, namely Portuguese doctors and nurses in central hospitals and health units in the metropolitan area of Lisbon, Portugal. In this context, 14 focus groups were held, lasting about 60 minutes, with participants of both genders, 64 female and 24 male, with an average of 43.2 years of age between 24 and 68 years old, having all signed a prior informed consent, with authorization from the ethics committee (process nº. 57/2019).
To address the content collected in the focus groups and in the interviews, ACQ was applied, the most prevalent approach in the qualitative analysis of messages , comprising a search for underlying topics in the analysed content  p. 557.
The results obtained show that the humor used in the therapeutic relationship, must be a humor for therapeutic purposes, that is, contributing to health results, it is valid in the therapeutic relationship, but it must be used in previously known patients, used with moderation, being necessary to previously evaluate the sociocultural conditions of the patients. If these requirements are met, humor has favorable effects on both patients and health professionals.
The group of participants was unanimous in affirming that effective therapeutic relationships need to be built, in health, day-to-day and in each context.
Therapeutic relationships must be empathic, available, with active listening,
Table 1. Biopsychosocial influences of humor.
Source: selection of authors.
which often presupposes the need for silence and other non-verbal aspects, with positive reinforcement of the patient’s action, between the health professional, who possesses technical and communicational skills, and the patient, to his/her state of fragility in varying degrees.
The results of 14 Focus groups, carried out between July and October 2019, with 88 health professionals, 25 doctors and 63 nurses show that humor helps to conduct a therapeutic relationship, being beneficial for both the patient and the health professional, but it must be well controlled and applied to situations in which the health professional already knows the patient in advance and recognizes in advance the moment of its application.
One of the medical participants in the Focus Groups warns of the care that must be taken when the health professional uses humor in the consultation. For this participant, it is necessary to evaluate “the climate, the moment in which the therapeutic relationship is found” in order to have “opportunity” and thus be favorable to the use of humor.
The use of humor presupposes a prior competence to know the other and their context, reinforcing what Damásio  underlines regarding the sociocultural knowledge of the other (p. 79). As this doctor says: “When we use humor, we are sure when that the person will have the reaction that we expect”.
One of the participants in focus groups says that is necessary to assess “in what stage the relationship is”, to safely improve “the therapeutic conversation”. Humor can be used in certain circumstances because the health professional already knows the patient, their social and cultural background, which influences their reaction to that mood.
Another of the participants says “we use humor with this person we have known for some time. Because we know how we are talking, and we know that this intervention with humor will be a way or technique to obtain a concrete health result.
Other participant in the focus group assumes “Humor alone does not produce the intended therapeutic effects”, and for this reason, health professionals reinforce: “It is not humor due to humor” (A9S). Specially because, sometimes, “there are people who don’t like humor”. And at that time, the health professional must know how to measure his words and the use of some satire, joke or other style of humor that may not please, for various reasons (economic, cultural, social, religious or other) the patient or the your family. Of the total number of participants, everyone uses humor, even if it is not intentional. The use depends on the conditions and the moment, and above all on the trust they have with the patient. A doctor, director of the internal medicine service, reported that situations arose in which the use of humor was not indicated, but that it is necessary to be able to react to these moments. This professional states that it is necessary to know how to use humor. Franzini  reinforces that when misused, humor can bring harm to people.
But most participants in the Portuguese qualitative study report that there is indeed “humor in the therapeutic relationship, and that it helps a lot in some phases”.
“We have to assess when it is, and who we are with. For example, in geriatric patients it worked very well “(A9S).
When asked whether health professionals use humor on a regular basis, most confirmed that they use it more positively in their appointments. The focus group participants and those interviewed in depth also consider that humor is “a good argument in the relationship” and that it contributes to producing health results.
As for this habitual or regular use of humor in consultations, it was also heard among the participants that, although there are some health professionals who know how to use humor, others do not know and do not do it more adequately. so they consider that learning to use humor is another communication technique that must be learned, among the other skills that are available to health professionals and that they benefit from their learning.
Among the therapeutic results of humor, the following stand out: an increase in the feeling of well-being and a decrease in previous negative states resulting from interpersonal relationships, and Martin , considers humor a social phenomenon.
Abreu (2011) explains that (good) mood therapy in health care processes helps both physiological and psychological processes, and is essential in the humanization of health, reinforced by Cassoli . Cassoli  defends the use of humor in health institutions, because it humanizes practices and reduces negative feelings in both professionals and patients, thus being a powerful and effective tool to deal with life’s obstacles.
But it is also necessary to evaluate if the humor used professionally, as the case of Rotton’s study  does not produce the same effects of “well-being” and satisfaction, leading these people who are dedicated to making humor to a less long life, due to the stress of his humorous work.
Effective communication in both directions, with a dose of humanization that involves technical skills, but also social and relational skills are also fundamental, in the opinion of the group of experts. And humor, used in small doses, considering that the health professional knows the patient can be effective in improving the results of the therapeutic relationship, the patient’s understanding.
Patients come in search of authority and often don´t make question to the health professional, to clear reasonable doubts. The group reinforced what the literature has confirmed: people with low health literacy are embarrassed to ask. Often, they do not even know what to question. They want to be told what to do. The literature on the subject also confirms that the patients ‘judgment about the professionals’ competencies, that is, the confidence they have in them, is not usually of a technical nature, but mainly based on the socio-emotional dimension of the relationship, which includes interpersonal communication . It is currently that the relationship has some past, as the patient is not a total stranger to the professional nor the health professional is anonymous to the patient.
There is a relationship of continuity, and it is in this relationship of continuity that trust is established .
It is in that trust that opens the way for humor to help achieve results.
A second aspect concerns the knowledge of the patient and his socio-cultural context. As Damásio  says, the stimuli that cause joy are consistent in the same individual and in individuals who share the same socio-cultural background (p. 79).
In this dialogical relationship there must be interaction, where communication is important and must be understood. The patient must believe what the professional says, in a true empathic process, with a biopsychosocial and spiritual alignment. One must realize what others want to explain. And humor helps in this process.
As  refer, the experience of positive emotions, such as humor, can lead to a momentary expansion of the set of thoughts and actions, which can bring an idea of greater self-efficacy , when dealing with problems specific (p. 81). Thus, and still according to these authors  positive emotions can lead to an increase in a person’s ability to initiate and maintain the actions that serve to treat a specific problem.
3.2. Improve Health Professional’s Humor Ability
Authors      who focus they research on humor bring us a group of interesting suggestions that allow professionals to improve their skills, namely individual or group interventions on laughter and humor.
Gelkopf  in a study on the use of humor in mental illness, although he considers that interventions are “personalized” for the individual or group, they seem to be the most effective way to use humor, highlights the opportunities that exist in non-personalized interventions, which suggest that laughter itself is enough to promote well-being, at least in the short term. These interventions include “Yoga Laughter” used as a way of health intervention, and “Laughter Classes”. Gonot-Schoupinsky  also suggests interventions associated with laughter and humor such as laughter yoga with laughter meditation, laughter and exercise programs, laughter qigong and laughter therapy.
Among the various results, the following stand out: regulate conversation; enhances social relations; produces pleasure; encourage social activities.
We can see in the Table 2 a set of essential points for working on humor and health.
Table 2. Ways to implement humor in health.
Humor contributes to better understanding and better understanding contributes to greater health literacy, so this greater understanding of the individual promotes their greater literacy in health, through a resilient process and investment in the technical and communicational competencies of the health professional.
Humor can be a technique, and with these instruments enable the health professional to deal with obstacles, constraints that exist during the consultation process. The health professional improves his skills, always taking into account the context, the social and cultural factors in which this patient-system moves. Patient knowledge, involvement and motivation produce better health outcomes .
Future Research and Implications
To better study the topic in the future, we suggest creating and organize workshops with professional specialists in humor, such as artists, clowns and other beginners, who know the techniques to use and can transmit some teachings for health. It should be noted that this technique was already used in the Postgraduate Course of Health Literacy at ISPA (http://www.ispa.pt/) in Portugal with a group of 20 health professionals, with very interesting results.
1) Franzini, l. R. (2001). Humor in therapy: the case for training therapists in its uses and risks. Journal General Psychology, 128(2), 170-193.
2) Ganz, F. & Jacobs, J. (2014). The effect of humor on elder mental and physical health. Geriatric Nursing, 35(3), 205-211. https://doi.org/10.1016/j.gerinurse.2014.01.005
3) Lefcourt, H.M., Davidson, K., Prkachin, K.M., & Mills, D.E. (1997). Humor as a stress moderator in the prediction of blood pressure obtained during five stressful tasks. Journal of Research in Personality, 31, 523-542.
4) Martin, R.A., & Dobbin, J.P. (1988). Sense of humor, hassles, and immunoglobulin A: Evidence for a stress-moderating effect of humor. International Journal of Psychiatry in Medicine, 18, 93-105.
5) Fredrickson, B.L. (2000). Cultivating positive emotions to optimize health and wellbeing. Prevention and Treatment, 3, 1-26.
6) Cai, C., Yu, L., Rong, L., & Zhong, H. (2014). Effectiveness of humor intervention for patients with schizophrenia: A randomized controlled trial. Journal of Psychiatric Research, 59, 174-178. https://doi.org/10.1016/j.jpsychires.2014.09.010
7) Lebowitz, K., Suh, S., Diaz, P., & Emery, C. (2011). Effects of humor and laughter on psychological functioning, quality of life, health status, and pulmonary functioning among patients with chronic obstructive pulmonary disease: A preliminary investigation. Heart & Lung: The Journal of Acute and Critical Care, 40(4), 310-319. https://doi.org/10.1016/j.hrtlng.2010.07.010
8) Martin, R.A. (2016). Humor and Mental Health. In Encyclopedia of Mental Health (2Ed.) (pp. 350-353). https://doi.org/10.1016/B978-0-12-397045-9.00044-6
9) Martin, R.A. (2001). Humor, laughter, and physical health: Methodological issues and research findings. Psychological Bulletin, 127, 504-519.
10) Martin, R.A., Kuiper, N.A., Olinger, L.J., & Dance, K.A. (1993). Humor, coping with stress, self-concept, and psychological well-being. Humor, 6, 89?104
11) Rotton, J. (1992).Trait humor and longevity: Do comics have the last laugh? Health Psychology, 11, 262-266.
12) INFLUENCE ON SOCIAL RELATIONS
13) Heintz, S. (2017). Putting a spotlight on daily humor behaviors: Dimensionality and relationships with personality, subjective well-being, and humor styles. Personality and Individual Differences, 104, 407-412. https://doi.org/10.1016/j.paid.2016.08.042
14) Jeludar, S., Jeludar, Z., Ahmadigatab, T., & Shayan, N. (2011). The Study of Relationship Between Sense of Humor and General Health in Students. Procedia-Social and Behavioral Sciences, 30, 2057-2060. https://doi.org/10.1016/j.sbspro.2011.10.399
15) Martin, R.A. (2007). The Psychology of Humor: An Integrative Approach. Burlington, MA: Elsevier Academic Press.
16) Sirigatti, S., Penzo, I., Giannetti, E., Casale, S., & Stefanile, C. (2016). Relationships between humorist profiles and psychological well-being. Personality and Individual Differences, 90, 219-224. https://doi.org/10.1016/j.paid.2015.11.011
17) Stieger, S., Formann, A., & Burger, C. (2010). Humor styles and their relationship to explicit and implicit self-esteem. Personality and Individual Differences, 50(5), 747-750. https://doi.org/10.1016/j.paid.2010.11.025
18) Torres-Marín, J., Navarro-Carrilo, G., & Carretero-Dios, H. (2018). Is the use of humor associated with anger management? The assessment of individual differences in humor styles in Spain. Personality and Individual Differences, 120, 193-201. https://doi.org/10.1016/j.paid.2017.08.040
19) Martin, R.A., Puhlik-Doris, P., Larsen, G., Gray, J., & Weir, K. (2003). Individual differences in uses of humor and their relation to psychological well-being: Development of the Humor Styles Questionnaire. Journal of Research in Personality.
20) Newman, M.G., & Stone, A.A. (1996). Does humor moderate the effects of experimentally induced stress? Annals of Behavioral Medicine, 18, 101-109.
 Almeida, C.V. (2018) Literacia em saúde: Capacitação dos profissionais de saúde: O lado mais forte da balança. In: Lopes, C. and Almeida, C.V., Eds., Literacia em saúde: Modelos, estratégias e intervenção, Edições ISPA Lisboa, 33-42.
 Nimmon, L. and Regehr, G. (2018) The Complexity of Patient Health Communication Social Networks: A Broadening of Physician Communication. Teaching and Learning in Medicine, 30, 352-366. https://doi.org/10.1080/10401334.2017.1407656
 Szasz, T.S. and Hollender, M.H. (1956) A Contribution to the Philosophy of Medicine: The Basic Models of the Doctor-Patient Relationship. A.M.A. Archives of Internal Medicine, 97, 585-592. https://doi.org/10.1001/archinte.1956.00250230079008
 Martin, R.A., Kuiper, N.A., Olinger, L.J. and Dance, K.A. (1993) Humor, Coping with Stress, Self-Concept, and Psychological Well-Being. Humor: International Journal of Humor Research, 6, 89-104. https://doi.org/10.1515/humr.19184.108.40.206
 Lefcourt, H.M., Davidson, K., Prkachin, K.M. and Mills, D.E. (1997) Humor as a Stress Moderator in the Prediction of Blood Pressure Obtained during Five Stressful Tasks. Journal of Research in Personality, 31, 523-542. https://doi.org/10.1006/jrpe.1997.2191
 Martin, R.A. and Dobbin, J.P. (1988) Sense of Humor, Hassles, and Immunoglobulin A: Evidence for a Stress-Moderating Effect of Humor. International Journal of Psychiatry in Medicine, 18, 93-105. https://doi.org/10.2190/724B-3V06-QC5N-6587
 Cai, C., Yu, L., Rong, L. and Zhong, H. (2014) Effectiveness of Humor Intervention for Patients with Schizophrenia: A Randomized Controlled Trial. Journal of Psychiatric Research, 59, 174-178. https://doi.org/10.1016/j.jpsychires.2014.09.010
 Lebowitz, K., Suh, S., Diaz, P. and Emery, C. (2011) Effects of Humor and Laughter on Psychological Functioning, Quality of Life, Health Status, and Pulmonary Functioning among Patients with Chronic Obstructive Pulmonary Disease: A Preliminary Investigation. Heart & Lung: The Journal of Acute and Critical Care, 40, 310-319.
 Jeludar, S., Jeludar, Z., Ahmadigatab, T. and Shayan, N. (2011) The Study of Relationship Between Sense of Humor and General Health in Students. Procedia-Social and Behavioral Sciences, 30, 2057-2060. https://doi.org/10.1016/j.sbspro.2011.10.399
 Stieger, S., Formann, A. and Burger, C. (2010) Humor Styles and Their Relationship to Explicit and Implicit Self-Esteem. Personality and Individual Differences, 50, 747-750.
 Torres-Marín, J., Navarro-Carrilo, G. and Carretero-Dios, H. (2018) Is the Use of Humor Associated with Anger Management? The Assessment of Individual Differences in Humor Styles in Spain. Personality and Individual Differences, 120, 193-201.
 Martin, R.A., Puhlik-Doris, P., Larsen, G., Gray, J. and Weir, K. (2003) Individual Differences in Uses of Humor and Their Relation to Psychological Well-Being: Development of the Humor Styles Questionnaire. Journal of Research in Personality, 37, 48-75.
 Heintz, S. (2017) Putting a Spotlight on Daily Humor Behaviors: Dimensionality and Relationships with Personality, Subjective Well-Being, and Humor Styles. Personality and Individual Differences, 104, 407-412. https://doi.org/10.1016/j.paid.2016.08.042
 Bruning, S.D. and Ledingham, J.A. (1998) Relationship Management in Public Relations: Dimensions of an Organization-Public Relationship. Public Relations Review, 24, 55-65.
 Gonot-Schoupinsky, F.N. and Garip, G. (2018) Laughter and Humour Interventions for Well-Being in Older Adults: A Systematic Review and Intervention Classification. Complementary Therapies in Medicine, 38, 85-91.