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https://doi.org/10.1177/0963721418760214

Current Directions in Psychological Science 2018, Vol. 27(5) 339 –344 © The Author(s) 2018 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/0963721418760214 www.psychologicalscience.org/CDPS

ASSOCIATION FOR PSYCHOLOGICAL SCIENCE

Research on the role that positive affect (PA) can play in physical health has surged over the last two decades. Studies have demonstrated that individuals with higher levels of PA live longer, have lower rates of illness and better illness outcomes, and report fewer symptoms and less pain (Boehm & Kubzansky, 2012; Diener & Chan, 2011; Pressman & Cohen, 2005). Researchers have affirmed many findings in replications and exten- sions of these studies, but there are also discrepancies that need to be explained.

One possible source of these discrepancies is a lack of sophistication in measurement conceptualization as well as a theoretical orientation held by most research- ers in this area that all types of PA are equal. It is a common assumption that all PA scales are equivalent, no matter what adjectives are included in the scale or the length, timing, or measurement category of the scale. We argue here that there are important distinc- tions with health-relevant consequences across mea- sures of PA. Thus, the goal of this article is to highlight and review new methodological considerations in PA measurement that will aid in improving future research in this field. Although not inclusive of all possible PA measurement issues, this article highlights critical

nuances that are gaining traction in the PA–health lit- erature as well as those that would be simple and straightforward to incorporate into studies in this area. Because of the importance of understanding how PA can improve health, we end with a short discussion of how these measurement issues interact with the mod- erators and mechanisms that may underlie the associa- tions between PA and health.

Before we begin, it is important to note that health can be operationalized in several different ways. Physical health is best defined by “hard” outcomes such as mor- tality and morbidity (e.g., incidence of disease). Although not related to health per se, there are also numerous promising mechanisms that might connect PA to health, such as behavioral (e.g., sleep, exercise) and physiologi- cal (e.g., inflammation, blood pressure) pathways that we will consider as evidence that may contribute to downstream health effects as well.

760214CDPXXX10.1177/0963721418760214Pressman, CrossPositive Affect in Health Research research-article2018

Corresponding Author: Sarah D. Pressman, University of California, Irvine, Department of Psychological Science, School of Social Ecology, 4201 Social and Behavioral Sciences Gateway, Irvine, CA 92697-7085 E-mail: [email protected]

Moving Beyond a One-Size-Fits-All View of Positive Affect in Health Research

Sarah D. Pressman and Marie P. Cross Department of Psychological Science, University of California, Irvine

Abstract Although the literature that connects positive affect (PA) to health has exploded over the last 20 years, the approach to studying this topic has remained simplistic. Specifically, researchers overwhelmingly rely on the principle that all PA is healthful, all of the time. Here, we review recent studies indicating that a more nuanced approach is valuable. In particular, we demonstrate that a more thoughtful approach to factors such as arousal, culture, timing, and measurement type results in a more complex picture of when PA is helpful and when it is not. Taking these issues into account also has implications for the types of mechanisms underlying these associations, as well as how other moderators might operate. Thus, we argue that considering these gradations will allow researchers to develop successful and theoretically based health interventions, untangle mixed findings, and enable a deeper understanding of the connection between PA and health.

Keywords positive affect, physical health, arousal, culture, stress

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340 Pressman, Cross

PA Measurement Considerations

Arousal

Research has long distinguished between subtypes of negative affect (e.g., depression, anger) and demon- strated that they have varying effects on physical health (e.g., Suls & Bunde, 2005). Although many theories of emotion support similar subcategorizations of PA—for example, the circumplex model (Russell, 1980) and broaden-and-build theory (Fredrickson, 2001)—this dif- ferentiation is rare in health, possibly because beliefs about a lack of PA subtypes persist (e.g., Shiota et al., 2014). One important way of differentiating PA is to consider self-reported arousal, given its likely overlap with physiological parameters that can influence health- relevant outcomes (Pressman & Cohen, 2005). Interest- ingly, the majority of existing studies on the link between PA and health use high-arousal (e.g., vigor; Robles, Brooks, & Pressman, 2009) or mid-arousal (e.g., happiness; Liu et al., 2016) assessments. This is likely a side effect of the popularity of high-arousal–oriented scales (e.g., Positive and Negative Affect Schedule; Watson, Clark, & Tellegen, 1988) and the frequent addi- tion of brief happiness assessments (e.g., one item) to large epidemiological surveys.

This scale choice may be more critical than research- ers realize, as there is growing evidence across an impressive array of outcomes that arousal has conse- quences. For example, many well-powered studies have revealed by and large that high- but not low-arousal trait (i.e., long lasting, dispositional) PA is responsible for benefits to important outcomes such as longevity (e.g., Pressman & Cohen, 2012; Shirom, Toker, Jacobson, & Balicer, 2010) and lower rates of infection in carefully designed experimentally induced illness paradigms (e.g., Cohen, Doyle, Turner, Alper, & Skoner, 2003). On the contrary, certain disease processes (e.g., airway and cardiovascular dysfunction) are worsened by high- arousal PA or, even more interestingly, have U-shaped connections (Armon, Melamed, Berliner, & Shapira, 2014; Ritz, Steptoe, DeWilde, & Costa, 2000). These mixed outcomes indicate that in addition to carefully considering arousal, researchers must factor in disease type and possible PA–health mechanisms for that out- come when interpreting their results and designing research.

What about low-arousal PA? Effects of calm may be present but are rarely examined, likely because of a frequent lack of inclusion or because of the file-drawer problem. Calm may be important for health but perhaps is being considered incorrectly. For example, we dem- onstrated recently that whereas trait calm was not help- ful for sleep, state (i.e., transient, single-day) calm was, but only on days with high stress (Pressman, Jenkins,

Kraft-Feil, Rasmussen, & Scheier, 2017). Thus, if only overall PA or trait assessments had been utilized in that study, or if stress had been ignored, no effect of calm would have been discovered. A lack of attention to these important measurement issues may therefore par- tially explain past null and mixed findings for calm (e.g., Cohen et al., 2003; Pressman & Cohen, 2012). Given the distinct autonomic profiles of different PA subtypes (Shiota, Neufeld, Yeung, Moser, & Perea, 2011), they may cancel each other out or dilute effects when combined into a single PA measure. Thus, there is growing evidence that a holistic PA approach should be supplemented by exploring arousal subcomponents in future work.

One additional critical issue when studying high- arousal PA is the directionality or meaning of the PA– health connection. Specifically, because of overlap in the use of adjectives such as “vigor” and “energetic” to indicate emotion (e.g., Watson et al., 1988), health and fitness (e.g., Ware et al., 1998), or physiological activa- tion (e.g., Dermer & Berscheid, 1972), it may be that vigor is good for you simply because it is an indicator of health in itself. Indeed, our recent study revealed that PA benefits on mortality were attributed almost exclusively to self-reports of feeling “active” (Petrie et al., 2018). Findings such as these raise the possibility that some past connections between PA and mortality are simply due to physical fitness, making it essential for future studies to consider not only arousal level but also whether effects are PA-based or artifacts of high- positive-arousal measurement overlap with health.

Timing and change

The current PA and physical health literature is heavily reliant on one-time measures of self-reported trait PA. We have previously suggested that this is the type of affect most likely to influence health because it has multiple opportunities to influence health-relevant behavior, physiology, and social processes (Pressman & Cohen, 2005), but there is now early evidence that alterations in our affect may also add something to our understanding of health. Affect variability encompasses changes in both different types of affect and the inten- sity of affect over time. Although the literature is rela- tively new and is focused on mental health (e.g., Gruber, Kogan, Quoidbach, & Mauss, 2013), we recently showed that PA variability is associated with a health-relevant physiological outcome: antibody response to vaccination. Specifically, we found that individuals who were both high in mean PA and high in PA variability had a lower antibody response to influenza vaccination than those who were high in mean PA but low in PA variability ( Jenkins, Hunter,

Positive Affect in Health Research 341

Cross, Acevedo, & Pressman, 2018). Thus, while aver- age affect captures information meaningful for health, average dynamics of affect may also matter. Although this literature is new, approximately a dozen studies on affect variability and psychological well-being (e.g., Jahng, Wood, & Trull, 2008; Trull et al., 2008) suggest that further exploration is warranted.

Although we advocate for the pursuit of affect vari- ability, researchers must also attend carefully to their simpler assessments and consider what timing makes sense conceptually for their health outcome of interest. All too often, vague time assessments or even single- day assessments of state affect are used to predict mor- tality years later (Liu et al., 2016; Steptoe & Wardle, 2011). From a biological standpoint, there is no reason to think that how you feel today should predict how long you live, except that your current feeling likely overlaps with how you typically feel. Although transient affect may have an important role in altering health- relevant mechanisms such as blood pressure, immune function, and healthy behavior, it is critical that research- ers stop using these inappropriately timed measures for predicting distant health outcomes, as this is potentially a source of the mixed findings in the literature (see Pressman & Cohen, 2005, for examples).

Non-self-report methods

There has been a tendency to equate emotional- expression measures with self-reported affect, such as using facial expressions in photographs and videos or emotional expressions in writing. In general, although these methods can enrich the literature by offsetting the limitations of self-reports, which can be biased by social desirability, memory, item order, and even current mood (Schwarz & Strack, 1999), it is also important to consider that affect data collected in these formats do not equate with self-report data and that there are distinct strengths and weaknesses of each. An advantage of writing, for example, is that researchers can look at both specific emotions and arousal without participant awareness of what is being studied. Indeed, emotion in writing has been tied to longer life (Danner, Snowdon, & Friesen, 2001; Pressman & Cohen, 2012), and experimental posi- tive writing has been tied to reduced illness (King, 2001). No study, however, has correlated these writing variables with self-reports of affect, and researchers admit that writing represents something distinct but possibly over- lapping with self-reports (Pennebaker & King, 1999). Thus, such findings must be interpreted accordingly.

Similarly, there is a lack of this consideration in the facial-expression literature. A recent failed replication and extension (Dufner et al., 2018) of the well-cited study showing that smiles in baseball card photographs

predicted longer life (Abel & Kruger, 2010) was inter- preted by the authors as an indication that PA does not predict mortality. Nowhere, however, did they question whether a smile in a baseball photograph is in fact an indication of PA, and to our knowledge, no study has shown this. Certainly, naturally occurring and manipu- lated smiles have been tied to affective outcomes (e.g., Ekman, Davidson, & Friesen, 1990), but even this finding has been called into question, for example, by a recent failed replication of the facial-feedback hypothesis (Wagenmakers et al., 2016). Smiles may represent PA to some extent, but they can also be faked, associated with negative outcomes, and an indication of something dif- ferent, such as self-presentation, professional image, or extraversion. It is even possible that smiling could have direct nonemotional effects on health via the known resulting musculature effects on the brain and body (Ekman et al., 1990). Surprisingly, these issues never seem to come up in the research on smiling. Therefore, although we advocate for more work in this area to be done, researchers need to start considering when smiles and their health and physiological effects are indicators of PA as opposed to, or in addition to, something else.

Cultural differences

While our own work has illustrated impressive world- wide consistency of the PA–health association (Pressman, Gallagher, & Lopez, 2013), cross-cultural research on PA and health has indicated that PA is not always helpful in regions that deemphasize its importance (e.g., East Asia; Yoo, Miyamoto, Rigotti, & Ryff, 2017). Although scarcely investigated, one explanation for these findings may be that ideal affect, or the affective state one ideally wants to feel, differs between cultures and that this dif- ference matters for health (Tsai, 2007). Although there is little work on its relevance to health, studies have found that ideal affect influences physician preference and medical adherence (Sims & Tsai, 2015; Sims, Tsai, Koopmann-Holm, Thomas, & Goldstein, 2014), which could have downstream impacts on important disease outcomes. This raises the interesting question of whether certain positive emotions are universally healthy or whether emotion desirability sways the impact. Thus, using a cultural framework and a consideration of ideal affect may be critical when interpreting PA–health asso- ciations and may partially explain some past mixed find- ings (e.g., Wagenmakers et al., 2016).

Not all PA measures are equal

Finally, it should be clear from the previous discussion of measurement that all PA measures are not equal. Although these measures may not be as distinct as

342 Pressman, Cross

apples and oranges, they may represent different variet- ies of apples with unique flavors and, thus, their down- stream impact may differ depending on that flavor. While we have discussed some measurement issues above, this was only a subset that shows promise as being relevant to the current health literature. It is also important to focus on the quality of the PA measure when interpreting the literature. For example, many measures are contaminated with non-PA variables (e.g., optimism, life satisfaction), which may result in differ- ent outcomes or dilute the overall PA measure. For example, in one review on psychological well-being and mortality (Chida & Steptoe, 2008), only about half of the 35 studies specifically investigated PA versus other positive assessments, which may have altered the results in important ways. Medical researchers also fre- quently do not attend to whether a scale is well con- structed and whether it captures the most health-relevant affect subtypes, and sometimes they haphazardly include single-item assessments of emotions such as happiness. This is rarely considered as a limitation in media-grabbing headlines or a possible reason for lim- ited PA effects in a health study (e.g., Liu et al., 2016).

Integrating New Measurements With Moderators and Mechanisms

A better consideration of measurement will not solve all of the problems related to moving this field forward. Several other moderators and mechanisms must also be considered in combination with this new attention to PA measurement. For example, despite long-held theories that PA may be most helpful to well-being in the context of stress—namely, the undoing hypothesis (Fredrickson & Levenson, 1998) and the stress-buffering theory (Pressman & Cohen, 2005)—the majority of work assumes a main effect of PA on health and ignores stress. This is critical given that recent studies have found support for stress buffering only in health- relevant behavior and immune function outcomes (e.g., Blevins, Sagui, & Bennett, 2017; Pressman et al., 2017). This type of issue is critical given the desire to apply positive psychology interventions to populations facing the stress of disease. Are there key times during stress- ful disease processes when PA is most helpful? Are there specific types of PA or PA arousal that are best suited to specific high-stress contexts or even specific disease types given their underlying physiology? These are unstudied areas and are central for PA interventions to be effectively designed and applied (Hernandez et al., 2017). Beyond disease and stress, we may also have to consider individual differences such as sex, age, and socioeconomic status, which, like culture, may play a role in which types of PA are helpful and when, given

that they are known to have influences on emotional expression and experiences. Thus, we have to stop thinking of PA and health as existing in a vacuum and pay greater attention to both when and why PA might help.

Context and measurement issues also play an impor- tant role in the mechanisms responsible for PA–health connections. Several pathways to health, such as physi- ological processes (e.g., immune, cardiovascular, endo- crine), behavioral processes (e.g., sleep, exercise, diet), and social processes (see Ong, 2010, and Pressman & Cohen, 2005, for detailed discussions), have been hypothesized to mediate the associations between PA and physical health. It is important to note, however, that the acting mechanism may differ across both the type of affect that is being investigated and the out- comes of interest. For example, calm might encourage physiological recovery from situations that are acute and difficult to control, whereas vigor might be tied to better active coping with certain energy-depleting stressors as they occur. It is also feasible that different affect types interact with other pathways, such as social- relationship processes and health behaviors, but that these effects will be moderated by factors discussed previously, such as cultural norms or timing. Thus, the type of affect, context, and health outcome may all alter what mechanism we look to for allowing PA to posi- tively or negatively influence health.

Conclusion

This article points to critical nuances in PA–health research that will strengthen the literature and sharpen attempts to move this field into intervention designs. Our list of measurement issues is not exhaustive, and other reviews have outlined additional critical factors, such as the need to control for negative affect (Pressman & Cohen, 2005), the value of taking a multimethod approach and considering underutilized data sources such as animal studies (Diener, Pressman, Hunter, & Delgadillo-Chase, 2017), and the importance of experi- mental work, in which factors such as PA dosage and disease timeline are considered (Hernandez et al., 2017). Furthermore, the issue of replication looms large within this field, as many studies have not been repli- cated because of cost (e.g., the prohibitive price of physiological assays, medical assessments, and paying participants for extensive longitudinal follow-ups). Pub- lic health and medical research is still largely resistant to the possibility that “fluffy” psychological concepts such as happiness could matter to hard biological out- comes. PA is poised, however, to be an essential ingre- dient in reducing the negative health impacts of stress on the populace, altering health trajectories, and

Positive Affect in Health Research 343

enhancing our understanding of who survives and thrives in the face of disease. We hope that this discus- sion spurs additional research on this vital topic and helps to convince even the staunchest critic to explore how, when, and why PA matters for physical wellness.