Emotional Health
Community-Based Mindfulness Program for Disease Prevention and Health Promotion: Targeting Stress Reduction
t s r
Brian M. Galla, PhD; Gillian A. O’Reilly, BS; M. Jennifer Kitil, MPH; Susan L. Smalley, PhD; David S. Black, PhD, MPH
PURPOSE
Abstract Purpose. Poorly managed stress leads to detrimental physical and psychological consequences that have implications for individual and community health. Evidence indicates that U.S. adults predominantly use unhealthy strategies for stress management. This study examines the impact of a community-based mindfulness training program on stress reduction. Design. This study used a one-group pretest-posttest design. Setting. The study took place at the UCLA Mindful Awareness Research Center in urban Los Angeles. Subjects. A sample of N ¼ 127 community residents (84% Caucasian, 74% female) were included in the study. Intervention. Participants received mindfulness training through the Mindful Awareness Practices (MAPs) for Daily Living I. Measures. Mindfulness, self-compassion, and perceived stress were measured at baseline and postintervention. Analysis. Paired-sample t-tests were used to test for changes in outcome measures from baseline to postintervention. Hierarchical regression analysis was fit to examine whether change in self-reported mindfulness and self-compassion predicted postintervention perceived stress scores. Results. There were statistically significant improvements in self-reported mindfulness (t ¼ 10.67, p , .001, d ¼ .90), self-compassion (t ¼ 8.50, p , .001, d ¼ .62), and perceived stress (t ¼ 9.28, p , .001, d ¼.78) at postintervention. Change in self-compassion predicted postintervention perceived stress (b ¼ .44, t ¼ 5.06, p , .001), but change in mindfulness did not predict postintervention perceived stress (b ¼ .04, t ¼ .41, p ¼ .68). Conclusion. These results indicate that a community-based mindfulness training program can lead to reduced levels of psychological stress. Mindfulness training programs such as MAPs may offer a promising approach for general public health promotion through improving stress management in the urban community. (Am J Health Promot 0000;00[0]:000–000.)
i F
e n i
l n
Key Words: Mindfulness, Stress Management, Stress Reduction, CommunityBased, Public Health, Health Promotion, Prevention Research. Manuscript format: research; Research purpose: intervention testing; Study design: quasi-experimental; Outcome measure: psychosocial; Setting: local community; Health focus: stress management; Strategy: skill building/behavior change; Target population: adults; Target population circumstances: geographic location
o
Psychological stress in daily life can have serious health consequences. Exposure to prolonged periods of acute and chronic stress is associated with the etiology and exacerbation of a broad array of illnesses. The connection between stress and health is at least partially explained by allostatic load theory, which posits that prolonged exposure to stress can weaken the allostatic process that returns the body to homeostasis after a stressful experience, resulting in sustained stress response, and eventually, detrimental health consequences.1,2 Physical health ramifications of prolonged stress include cardiovascular morbidity,3–5 metabolic dysfunction,3 hormonal dysfunction,6 autoimmune disorders,5,7 obesity,8 and some cancers.5,7 Increased risk for mental health disorders, including emotional disturbances,6 major depression,9–11 chronic anxiety,12 and cognitive impairment,13 have also been linked to stress. These health consequences make poorly managed and persistent levels of psychological stress a notable public health concern.
Brian M. Galla, PhD, is with the Department of Psychology, University of Pennsylvania, Philadelphia, Pennsylvania. Gillian A. O’Reilly, BS, and David S. Black, PhD, MPH, are with the Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, California. M. Jennifer Kitil, MPH, is with the Department of Educational and Counselling Psychology, and Special Education, University of British Columbia, Vancouver, British Columbia, Canada. Susan L. Smalley, PhD, is with the Department of Psychiatry & Biobehavioral Sciences, and the Mindful Awareness Research Center at the UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, California. Send reprint requests to David S. Black, PhD, MPH, Department of Preventive Medicine, University of Southern California Keck School of Medicine, 2001 N Soto St, Suite 302D, MC 9239, Los Angeles, CA 90032; [email protected]. This manuscript was submitted November 7, 2013; revisions were requested February 15, 2014; the manuscript was accepted for publication April 5, 2014. Copyright Ó 0000 by American Journal of Health Promotion, Inc. 0890-1171/00/$5.00 þ 0 DOI: 10.4278/ajhp.131107-QUAN-567
American Journal of Health Promotion
Month 0000, Vol. 0, No. 0
0
Psychological stress and related health disorders are an increasing problem in the United States. According to a report by the American Psychological Association, 44% of U.S. adults have experienced an increase in psychological stress in the past 5 years.14 Stress severity is also a growing issue. In a survey of a nationally representative sample conducted in 2013, 20% of U.S. adults reported that the stress they regularly experienced was extreme in nature.15 The health burden of stress on the American population is reflected in the ailments that are reported in health care settings: an estimated 60% to 80% of primary care medical visits in this country involve stress-related health complaints.16 It is clear that psychological stress is a substantial and growing problem among the U.S. adult population that requires mitigation strategies. Stress reduction programs can decrease the risk for many diseases and improve the outcomes of many stressrelated illnesses.16–19 Despite this, many people rely on maladaptive stress-coping strategies, such as engaging in sedentary activities, engaging in unhealthful eating behaviors, and consuming alcohol, which do little to help with long-term stress management.14 One factor that may contribute to the lack of adaptive stress management skills among the general population is poor access to stress management counseling. A recent study that surveyed physicians in the United States reported low rates of stress reduction and management counseling for patients by primary care physicians.20 Lack of time during primary care visits and an overburdened health care system have been cited as reasons for deficits in such care.16,20,21 The lack of stress reduction counseling in primary medical care highlights the need for stress management skills training programs that people can readily access in their communities, which are transportable across diverse populations. Large-scale and community-based programs for stress management hold potential for answering this unmet need. One approach to helping people more wisely manage stress that can be applied in the community setting is
0
American Journal of Health Promotion
experience. The classes lay the foundation for students to understand basic principles of mindfulness, to develop a personal meditation practice, and to apply the principles in their daily lives on an ongoing basis. MAPs I classes were open to the general public for a fee comparable to similar courses being offered in the community, with reduced fee–waivers and work-exchange opportunities available. Classes were advertised by using flyers, e-mails, and announcements in local newspapers, magazines, and Web sites. Individuals self-enrolled in MAPs I without interference by the research team. All individuals aged 18 years and older who attended the first MAPs I class in a 6-week series between fall 2008 and spring 2009 were invited to complete a confidential survey before and after the intervention whereby no identifying information was collected. Individuals younger than 18 years could enroll in the class but were not permitted to participate in the study. Before the start of the first class, participants provided consent and completed the baseline questionnaire measures. On the last day of the MAPs course, participants completed the final set of questionnaires, provided demographic information, and completed a course evaluation. Participation was entirely voluntary, and participants could choose not to complete any question. Anonymous identifiers were used to match the presurveys and postsurveys. This study can be conceptualized as a naturalistic field evaluation of the MAPs I curriculum, as it is delivered day-to-day in the community by self-enrolled residents. Study protocols were approved by the UCLA Institutional Review Board (No. 07-308A). Self-reported demographic data collected at postintervention (available for 78% of the sample) indicated that approximately 84% were Caucasian, 8% were Asian, 6% were Latino, and approximately 1% were mixed race; 74% were female. The participants reported a median income of equal to or less than $150,000, with a range from under $25,000 to over $250,000.
t s r
i F
e n i
l n
o
mindfulness training. Mindfulness training uses various exercises to cultivate a quality of consciousness that is characterized by a nonjudgmental, moment-to-moment attentiveness to experiences, thoughts, and emotions.22–25 The skills cultivated through mindfulness training help override and perhaps even replace maladaptive, and largely reactive, responses to stressors.24 Over time and with sustained mindfulness practice, the enhanced awareness of present-moment experience cultivated through mindfulness training enables more deliberate, conscious responses to stressful challenges, thus facilitating more adaptive selfregulation, stress reduction, and emotion management.24,26,27 These characteristics of mindfulness training make it a promising intervention focus for stress-related health promotion and disease prevention in the general community. Mindfulness training for stress reduction has been successfully implemented in clinical populations through formal programs such as Mindfulness-Based Stress Reduction.25,28–30 However, less is known about how mindfulness training can be used for stress reduction in the broader community and for the promotion of public health. The current study implemented a mindfulness program for stress reduction in a community setting. The objective of the study was to determine if a community-based mindfulness training program might help reduce psychological stress levels in a community-based sample of adults who were novices to mindfulness training. We hypothesized that participation in the mindfulness program would result in improved mindfulness, improved self-compassion, and reduced perceived stress from baseline to postintervention.
METHODS Sample and Design The sample consisted of N ¼ 127 adults (mean age ¼ 45.3 years, SD ¼ 14.6 years) attending Mindful Awareness Practices (MAPs) for Daily Living I offered at the UCLA Mindful Awareness Research Center located in a large urban Los Angeles community. MAPs I is the introductory level course offered to individuals without prior meditation
Self-Report Measures Mindfulness. Participants self-reported dispositional mindfulness levels by using the Kentucky Inventory of Mind-
Month 0000, Vol. 0, No. 0
fulness Skills (KIMS),31 a 39-item questionnaire that taps four distinct mindfulness-related skills or facets: Acting with Awareness (e.g., ‘‘When I do things, my mind wanders off and I’m easily distracted’’), Observing (e.g., ‘‘I notice changes in my body, such as whether my breathing slows down or speeds up’’), Describing (e.g., ‘‘I’m good at finding words to describe my feelings’’), and Nonjudgmental Acceptance (e.g., ‘‘I tell myself that I shouldn’t be feeling the way I’m feeling’’). Items are rated from 1 ¼ never or very rarely true to 5 ¼ very often or always true, and scores are computed by averaging the items within each facet. The items can also be combined to form a composite score of mindfulness, with higher scores indicating higher total mindfulness. The KIMS mean score, as well as the four facet scores, showed high internal consistency reliability estimates at baseline and postintervention (all Cronbach a . .80). Self-Compassion. Participants reported on their self-compassion by using the Self-Compassion Scale (SCS),32 a 26item scale that assesses six distinct skills or facets of self-compassion: Self-Kindness (e.g., ‘‘I try to be understanding and patient toward aspects of my personality I don’t like’’), Self-Judgment (e.g., ‘‘I’m disapproving and judgmental about my own flaws and inadequacies’’), Common Humanity (e.g., ‘‘I try to see my failings as part of the human condition’’), Isolation (e.g., ‘‘When I think about my inadequacies it tends to make me feel more separate and cut off from the rest of the world’’), Mindfulness (e.g., ‘‘When something painful happens I try to take a balanced view of the situation’’), and Overidentification (e.g., ‘‘When I’m feeling down I tend to obsess and fixate on everything that’s wrong.’’). Items are rated from 1 ¼ almost never to 5 ¼ almost always, and scores are computed by averaging the items within each subscale. The SCS mean score, as well as the six facet scores, showed adequate internal reliability estimates at baseline and postintervention (all Cronbach a . .74).
Table 1 Correlation Coefficients Between Mindfulness, Self-Compassion, and Perceived Stress† Variables 1. 2. 3. 4. 5. 6.
Perceived Stress. Participants also reported on the degree to which they appraised their current life demands as
American Journal of Health Promotion
SD
2
3
4
5
6
3.06 3.41 2.19 1.70 2.65 3.06
0.40 0.38 0.66 0.62 0.67 0.65
0.56**
0.36** 0.17
0.21* 0.39** 0.57**
0.49** 0.28** 0.66** 0.47**
0.22* 0.55** 0.43** 0.65** 0.67** –
t s r
† Coefficients reported are Pearson r. M indicates mean; KIMS, Kentucky Inventory of Mindfulness Skills composite score; PSS, Perceived Stress Scale composite score; and SCS, SelfCompassion Scale composite score. * p , 0.05. ** p , 0.01.
i F
overwhelming, unpredictable, and uncontrollable by using the 10-item Perceived Stress Scale (PSS).33 Items are rated from 1 ¼ never to 5 ¼ very often (e.g., ‘‘In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?’’). A total score is calculated by taking the mean of all items, with higher scores representing higher perceived stress (Cronbach a ¼ .87 [baseline]; Cronbach a ¼ .87 [postintervention]).
e n i
l n
o
Baseline KIMS Postintervention KIMS Baseline PSS Postintervention PSS Baseline SCS Postintervention SCS
M
Intervention Mindful Awareness Practices for Daily Living I. MAPs I is a weekly, 2-hour, sixsession, group-based course in mindfulness meditation, which is available to all residents in the community. An experienced mindfulness teacher with 20 years of mindfulness meditation practice and teaching delivered the MAPs program curriculum to participants. Session titles by week include (1) Introduction to Mindfulness, (2) Listening, Embodiment, and Obstacles, (3) Working With Pain, (4) Difficult Emotions and Cultivating Positive Emotions, (5) Thoughts and Mindful Interactions, and (6) Loving Kindness and Class Wrap-up. Mindfulness exercises embedded in the curriculum include mindful sitting meditation, mindful eating, appreciation meditation, loving-kindness meditation, and mindful movement such as mindful walking. Participants engage in an average of 20 to 30 minutes of mindful experiential practice during each class. Participants are also
provided with a textbook on mindfulness,34 accompanied by a meditation compact disc for recommended daily practice at home. Mindfulness practice is assigned as homework beginning with 5 minutes daily and advancing to 20 minutes daily by the program’s end.
RESULTS Descriptive Statistics As shown in Table 1, before and after mindfulness training, both selfreported mindfulness and self-compassion scores were negatively correlated with perceived stress. Moreover, mindfulness and self-compassion scores showed strong positive correlations with each other before and after mindfulness training.
MAPS I Training Improvements in Mindfulness, Self-Compassion, and Perceived Stress. Our primary hypothesis was that participation in MAPs I training would result in improvements in self-reported mindfulness, self-compassion, and reductions in perceived stress from baseline to postintervention. As shown in Table 2, this hypothesis was confirmed through a series of pairedsample t-tests. All three variables (and their individual facet scores) showed significant improvement at immediate postintervention. Effect size estimates (range ¼ .33–.90) were of moderate to large magnitude.35 Differences in postintervention outcomes by sex and ethnicity were minimal: women had higher Observe scores (t ¼ 2.80, p ¼
Month 0000, Vol. 0, No. 0
0
Table 2 Paired t-Tests Examining Change in Self-Reported Mindfulness, Self-Compassion, and Perceived Stress From Baseline to Postintervention† Pre-MAPs
Post-MAPs
Variables
M
SD
M
SD
d
KIMS Observe KIMS Describe KIMS Act with Awareness KIMS Acceptance KIMS Composite Score SCS Self-Kindness SCS Self-Judgment SCS Common Humanity SCS Isolation SCS Mindfulness SCS Overidentified SCS Composite Score PSS
3.24 3.55 2.66 2.82 3.06 2.69 3.60 2.85 3.40 3.02 3.57 2.65 2.20
0.56 0.69 0.54 0.74 0.40 0.75 0.83 0.84 0.93 0.75 0.84 0.67 0.66
3.66 3.77 2.97 3.23 3.41 3.05 3.09 3.14 2.88 3.31 3.11 3.06 1.70
0.52 0.65 0.48 0.73 0.38 0.73 0.80 0.82 0.93 0.67 0.80 0.65 0.62
0.78* 0.33* 0.61* 0.56* 0.90* 0.49* 0.63* 0.35* 0.56* 0.41* 0.56* 0.62* 0.78*
e n i
l n
Exploratory Analyses Predicting Postintervention Change in Perceived Stress. We next examined whether change in selfreported mindfulness or self-compassion scores from baseline to postintervention predicted change in perceived stress at postintervention. First, we calculated standardized residual change scores by fitting a regression model in which baseline mindfulness composite scores predicted postintervention mindfulness composite scores. A separate regression analysis was fit to compute change scores for the selfcompassion composite scores. We next fit a hierarchical regression analysis predicting change in perceived stress from baseline to postintervention. Step 1 included baseline perceived stress, while residual change scores for mindfulness and self-compassion were both entered in step 2. As shown in Table 3, change in self-compassion (b ¼.44, t ¼ 5.06, p , .001), but not mindfulness (b ¼ .04, t ¼ .41, p ¼ .68), predicted postintervention perceived stress, above and beyond baseline perceived stress.
o
0
American Journal of Health Promotion
DISCUSSION
t s r
i F
† MAPs indicates Mindful Awareness Practices; M, mean; KIMS, Kentucky Inventory of Mindfulness Skills; SCS, Self-Compassion Scale; and PSS, Perceived Stress Scale. * p , 0.001.
.006), Describe scores (t ¼ 2.81, p ¼ .006), and Common Humanity scores (t ¼ 1.95, p ¼ .054) at postintervention than men. No other differences emerged between groups at postintervention.
possible mechanism for the improvement of stress through self-compassion. It appears from the variables assessed that it was not direct improvements in mindfulness skills that led to decreased stress, but improvements in self-compassion brought about through mindfulness training. Prior cross-sectional work has also shown that, compared to mindfulness, self-compassion accounted for 10 times more unique variance in anxiety, depression, and quality of life in a large sample of distressed adults.36 From a practice perspective, mindfulness training directly cultivates self-compassion through its effect on enhancing personal insight into the linkages between sensations, emotions, thoughts, and habitual reactions that produce psychological suffering. Thus, mindfulness training may reduce stress by helping people cultivate adaptive compassionate attitudes and approaches to internal and external sources of stress, which ultimately mitigates the impact of these stressors on psychological well-being. Future studies exploring the role of mindfulness on health and well-being should also include direct assessments of selfcompassion so that the effectiveness of each on stress reduction can be evaluated. Findings from this study parallel previous research but also provide new insights into the use of communitybased mindfulness training for gener-
Our results demonstrate that mindfulness, self-compassion, and perceived stress significantly changed in the direction of improvement after completion of a community-based mindfulness training program offered to all residents of the general community who sought out the program to deal with a variety of life challenges. The effect sizes for changes in overall mindfulness, self-compassion, and perceived stress were moderate to large (d ¼ .62 for SCS, d ¼ .78 for PSS, d ¼ .90 for KIMS). At postintervention, lower perceived stress scores were correlated with higher total mindfulness scores and higher self-compassion scores. Further, we found that postintervention perceived stress scores were predicted by changes in self-compassion. This is the first published study to examine the effects of the MAPS I program on psychological stress in a sample of adult community residents. Overall, the results from this study suggest that an accessible, communitybased mindfulness program can help people perceive less stress in day-to-day life. The findings from this study provide insight into the impact of mindfulness training on psychological stress and a
Table 3 Hierarchical Regression Analysis Predicting Postintervention Perceived Stress From Change in Self-Reported Mindfulness and Self-Compassion Scores†
Variables Baseline PSS Changes in KIMS Changes in SCS R2 DR2
Step 1
Step 2
b 0.57*
b 0.58* 0.04 0.44* 0.54 0.21*
0.33
† PSS indicates Perceived Stress Scale; KIMS, Kentucky Inventory of Mindfulness Skills; and SCS, Self-Compassion Scale. * p , 0.001.
Month 0000, Vol. 0, No. 0
alized health promotion and disease prevention. The effectiveness of mindfulness training for stress reduction is well supported by previous research. Mindfulness programs have been shown to reduce stress in various populations, including patients diagnosed with cancer,37 organ transplant recipients,38 patients with chronic illnesses,39 and specific healthy populations including students and medical professionals.40 The effectiveness of community-based interventions for stress-related health problems is also supported by a small number of studies. Community-based programs have been used to improve acute posttraumatic stress,41 hypertension,42 and depression and anxiety.43 Mindfulness training programs reported in the research literature44,45 are most often housed within medical centers not geared toward community accessibility. Findings from our study only begin to fill the gaps in the research regarding general stress management in the community, and provide support for the use of community-based mindfulness skills training as an approach to meet the needs of stress reduction at the general community level. Some limitations of this study warrant discussion. The sample was composed predominantly of Caucasian and female participants, which could limit the generalizability of the findings. Assessments were conducted at preintervention and postintervention, so long-term maintenance of change in the outcomes cannot be determined here. Given the naturalistic field evaluation intent of the study, no comparison group was available; therefore, threats to internal validity are plausible such as history, maturation, testing, regression to the mean, and group support. Future research should determine if community-based mindfulness training programs are effective for stress management and reduction in more diverse populations. Comparison groups in future studies could be included to determine the comparative efficacy of mindfulness training to other stress reduction strategies offered in the community, such as fitness and social support programs, as well as to control for other nonspecific effects of social support on stress reduction.
CONCLUSIONS Findings from this study suggest that mindfulness, self-compassion, and stress can improve through mindfulness training in a community-based program using a field evaluation approach. The moderate to large effect sizes for changes in mindfulness, selfcompassion, and perceived stress suggest that mindfulness training might be a promising intervention for producing effects that are relevant for community-based disease prevention
o
American Journal of Health Promotion
t s r
Acknowledgments
The authors are grateful to Diana Winston for codevelopment and teaching of the MAPs Curriculum. This research study was supported by the Pettit Foundation and postprogram support by NIH/NCI (T32CA009492) to Ms O’Reilly. This research was conducted at the UCLA Mindful Awareness Research Center (www.marc.ucla.edu).
i F
SO WHAT? Implications for Health Promotion Practitioners and Researchers
What is already known on this topic? Evidence from mindfulness-based interventions in clinical and subclinical (those who suffer from symptoms of stress but are not characterized by or sampled on the basis of a diagnosed psychological or physiological disorder) populations indicates that mindfulness training can lead to improvements in psychological stress. However, little is known about the effects of mindfulness when routinely deployed in a community context for the general population. Accessible, communitybased strategies for stress reduction are needed to reduce the burden of psychological stress on individuals residing in the urban community. What does this article add? This study found that mindfulness training implemented through a community-based program led to self-reported reductions in perceived stress. Changes in self-compassion predicted postintervention perceived stress, suggesting that improved selfcompassion is a potential mechanism for the impact of mindfulness training on perceived stress. What are the implications for health promotion practice or research? The findings from this study demonstrate that mindfulness training through a community-based program such as MAPs can have a beneficial impact on perceived psychological stress in an urban population. Mindfulness training may offer a promising approach for general public health promotion and disease prevention efforts by its function to enhance self-compassion and alleviate stress.
e n i
l n
and health promotion efforts. Considering the broad health implications of persistent psychological stress, designing accessible interventions that are available in the community, which help individuals to successfully reduce stress, is critical for maintaining health and wellness in the face of our everdemanding lifestyles.
References
1. McEwen BS. Protective and damaging effects of stress mediators. N Engl J Med. 1998;338:171–179. 2. McEwen BS, Stellar E. Stress and the individual: mechanisms leading to disease. Arch Intern Med. 1993;153:2093–2101. 3. Brotman DJ, Golden SH, Wittstein IS. The cardiovascular toll of stress. Lancet. 2007; 370(9592):1089–1100. 4. Torpy JM, Lynm C, Glass RM. JAMA patient page. Chronic stress and the heart. JAMA. 2007;298:1722. 5. Kiecolt-Glaser JK, McGuire L, Robles TF, Glaser R. Emotions, morbidity, and mortality: new perspectives from psychoneuroimmunology. Annu Rev Psychol. 2002;53:83–107. 6. Ehlert U, Gaab J, Heinrichs M. Psychoneuroendocrinological contributions to the etiology of depression, posttraumatic stress disorder, and stress-related bodily disorders: the role of the hypothalamus, pituitary, adrenal axis. Biol Psychol. 2001;57:141–152. 7. Cohen S, Janicki-Deverts D, Miller GE. Psychological stress and disease. JAMA. 2007;298:1685–1687. 8. Dallman MF, Pecoraro N, Akana SF, et al. Chronic stress and obesity: a new view of comfort food. Proc Natl Acad Sci U S A. 2003;100:11696–11701. 9. Belmaker RH, Agam G. Major depressive disorder. New Engl J Med. 2008;358:55–68. 10. Hampton T. Chronic stress and depression. JAMA. 2012;308:444. 11. Pittenger C, Duman RS. Stress, depression, and neuroplasticity: a convergence of mechanisms. Neuropsychopharmacology. 2007;33:88–109. 12. Roozendaal B, McEwen BS, Chattarji S. Stress, memory and the amygdala. Nat Rev Neurosci. 2009;10:423–433. 13. Lupien SJ, McEwen BS, Gunnar MR, Heim C. Effects of stress throughout the lifespan on the brain, behaviour and cognition. Nat Rev Neurosci. 2009;10:434–445. 14. American Psychological Association. Stress in America: Our Health at Risk, 2012. Washington, DC: American Psychological Association; 2012.
Month 0000, Vol. 0, No. 0
0
15. American Psychological Association. Stress in America: Missing the Health Care Connection. Washington, DC: American Psychological Association; 2013. 16. Avey H, Matheny KB, Robbins A, Jacobson TA. Health care providers’ training, perceptions, and practices regarding stress and health outcomes. J Natl Med Assoc. 2003;95:833, 836–845. 17. Gerber M, Puhse U. Review article: do ¨ exercise and fitness protect against stressinduced health complaints: a review of the literature. Scand J Public Health. 2009;37: 801–819. 18. Cabral P, Meyer HB, Ames D. Effectiveness of yoga therapy as a complementary treatment for major psychiatric disorders: a meta-analysis. Prim Care Companion CNS Disord. 2011;13:1–12. 19. Rainforth MV, Schneider RH, Nidich SI, et al. Stress reduction programs in patients with elevated blood pressure: a systematic review and meta-analysis. Curr Hypertens Rep. 2007;9:520–528. 20. Nerurkar A, Bitton A, Davis RB, Phillips RS, Yeh G. When physicians counsel about stress: results of a national study. JAMA Intern Med. 2013;173:76–77. 21. Chen LM, Farwell WR, Jha AK. Primary care visit duration and quality: does good care take longer: effect of duration and quality on primary care. Arch Intern Med. 2009;169:1866–1872. 22. Brown KW, Ryan RM. The benefits of being present: mindfulness and its role in psychological well-being. J Pers Soc Psychol. 2003;84:822–848. 23. Daubenmier J, Lin J, Blackburn E, et al. Changes in stress, eating, and metabolic factors are related to changes in telomerase activity in a randomized mindfulness intervention pilot study. Psychoneuroendocrinology. 2012;37:917–928. 24. Grossman P, Niemann L, Schmidt S, Walach H. Mindfulness-based stress reduction and health benefits: a metaanalysis. J Psychosom Res. 2004;57:35–43.
0
American Journal of Health Promotion
38.
39.
40.
trial: the effect of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients. Psychosom Med. 2000; 62:613–622. Gross CR, Kreitzer MJ, Russas V, et al. Mindfulness meditation to reduce symptoms after organ transplant: a pilot study. Adv Mind Body Med. 2004;20:20–29. Simpson J, Mapel T. An investigation into the health benefits of mindfulnessbased stress reduction (MBSR) for people living with a range of chronic physical illnesses in new Zealand. N Z Med J. 2011; 124(1338):68–75. Chiesa A, Serretti A. Mindfulness-based stress reduction for stress management in healthy people: a review and meta-analysis. J Altern Complement Med. 2009;15:593–600. Macy RD, Behar L, Paulson R, et al. Community-based, acute posttraumatic stress management: a description and evaluation of a psychosocial-intervention continuum. Harv Rev Psychiatry. 2004;12: 217–228. Schneider RH, Staggers F, Alexander CN, et al. A randomized controlled trial of stress reduction for hypertension in older African Americans. Hypertension. 1995;26: 820–827. Sharplin GR, Jones SBW, Hancock B, et al. Mindfulness-based cognitive therapy: an efficacious community-based group intervention for depression and anxiety in a sample of cancer patients. Med J Aust. 2010;193(5 suppl):S79–S82. Goyal M, Singh S, Sibinga EMS, et al. Meditation programs for psychological stress and well-being: A systematic review and meta-analysis. JAMA Intern Med. 2014; 174:357–368. Black DS, Milam J, Sussman S. Sittingmeditation interventions among youth: A review of treatment efficacy. Pediatrics. 2009;124:e532–e541.
t s r
i F
e n i
l n
o
25. Ludwig DS, Kabat-Zinn J. Mindfulness in medicine. JAMA. 2008;300:1350–1352. 26. Bishop SR. What do we really know about mindfulness-based stress reduction? Psychosom Med. 2002;64:71–83. 27. Reibel DK, Greeson JM, Brainard GC, Rosenzweig S. Mindfulness-based stress reduction and health-related quality of life in a heterogeneous patient population. Gen Hosp Psychiatry. 2001;23:183–192. 28. Kabat-Zinn J. Full Catastrophe Living: The Program of the Stress Reduction Clinic at the University of Massachusetts Medical Center. New York, NY: Delta; 1990. 29. Kabat-Zinn J. Mindfulness-based interventions in context: past, present, and future. Clin Psychol. 2003;10:144–156. 30. Kabat-Zinn J. An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results. Gen Hosp Psychiatry. 1982;4:33–47. 31. Baer RA, Smith GT, Allen KB. Assessment of mindfulness by self-report: the Kentucky inventory of mindfulness skills. Assessment. 2004;11:191–206. 32. Neff KD. The development and validation of a scale to measure self-compassion. Self Identity. 2003;2:223–250. 33. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24:385–396. 34. Smalley SL, Winston D. Fully Present: The Science, Art, and Practice of Mindfulness. Philadelphia, Pa: Da Capo Press; 2010. 35. Cohen J. Statistical Power Analysis for the Behavioral Sciencies. Hillsdale, NJ: Routledge; 1988. 36. Van Dam NT, Sheppard SC, Forsyth JP, Earleywine M. Self-compassion is a better predictor than mindfulness of symptom severity and quality of life in mixed anxiety and depression. J Anxiety Disord. 2011;25: 123–130. 37. Speca M, Carlson LE, Goodey E, Angen M. A randomized, wait-list controlled clinical
41.
42.
43.
44.
45.
Month 0000, Vol. 0, No. 0
Community-Based Mindfulness Program for Disease Prevention and Health Promotion: Targeting Stress Reduction
t s r
Brian M. Galla, PhD; Gillian A. O’Reilly, BS; M. Jennifer Kitil, MPH; Susan L. Smalley, PhD; David S. Black, PhD, MPH
PURPOSE
Abstract Purpose. Poorly managed stress leads to detrimental physical and psychological consequences that have implications for individual and community health. Evidence indicates that U.S. adults predominantly use unhealthy strategies for stress management. This study examines the impact of a community-based mindfulness training program on stress reduction. Design. This study used a one-group pretest-posttest design. Setting. The study took place at the UCLA Mindful Awareness Research Center in urban Los Angeles. Subjects. A sample of N ¼ 127 community residents (84% Caucasian, 74% female) were included in the study. Intervention. Participants received mindfulness training through the Mindful Awareness Practices (MAPs) for Daily Living I. Measures. Mindfulness, self-compassion, and perceived stress were measured at baseline and postintervention. Analysis. Paired-sample t-tests were used to test for changes in outcome measures from baseline to postintervention. Hierarchical regression analysis was fit to examine whether change in self-reported mindfulness and self-compassion predicted postintervention perceived stress scores. Results. There were statistically significant improvements in self-reported mindfulness (t ¼ 10.67, p , .001, d ¼ .90), self-compassion (t ¼ 8.50, p , .001, d ¼ .62), and perceived stress (t ¼ 9.28, p , .001, d ¼.78) at postintervention. Change in self-compassion predicted postintervention perceived stress (b ¼ .44, t ¼ 5.06, p , .001), but change in mindfulness did not predict postintervention perceived stress (b ¼ .04, t ¼ .41, p ¼ .68). Conclusion. These results indicate that a community-based mindfulness training program can lead to reduced levels of psychological stress. Mindfulness training programs such as MAPs may offer a promising approach for general public health promotion through improving stress management in the urban community. (Am J Health Promot 0000;00[0]:000–000.)
i F
e n i
l n
Key Words: Mindfulness, Stress Management, Stress Reduction, CommunityBased, Public Health, Health Promotion, Prevention Research. Manuscript format: research; Research purpose: intervention testing; Study design: quasi-experimental; Outcome measure: psychosocial; Setting: local community; Health focus: stress management; Strategy: skill building/behavior change; Target population: adults; Target population circumstances: geographic location
o
Psychological stress in daily life can have serious health consequences. Exposure to prolonged periods of acute and chronic stress is associated with the etiology and exacerbation of a broad array of illnesses. The connection between stress and health is at least partially explained by allostatic load theory, which posits that prolonged exposure to stress can weaken the allostatic process that returns the body to homeostasis after a stressful experience, resulting in sustained stress response, and eventually, detrimental health consequences.1,2 Physical health ramifications of prolonged stress include cardiovascular morbidity,3–5 metabolic dysfunction,3 hormonal dysfunction,6 autoimmune disorders,5,7 obesity,8 and some cancers.5,7 Increased risk for mental health disorders, including emotional disturbances,6 major depression,9–11 chronic anxiety,12 and cognitive impairment,13 have also been linked to stress. These health consequences make poorly managed and persistent levels of psychological stress a notable public health concern.
Brian M. Galla, PhD, is with the Department of Psychology, University of Pennsylvania, Philadelphia, Pennsylvania. Gillian A. O’Reilly, BS, and David S. Black, PhD, MPH, are with the Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, California. M. Jennifer Kitil, MPH, is with the Department of Educational and Counselling Psychology, and Special Education, University of British Columbia, Vancouver, British Columbia, Canada. Susan L. Smalley, PhD, is with the Department of Psychiatry & Biobehavioral Sciences, and the Mindful Awareness Research Center at the UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, California. Send reprint requests to David S. Black, PhD, MPH, Department of Preventive Medicine, University of Southern California Keck School of Medicine, 2001 N Soto St, Suite 302D, MC 9239, Los Angeles, CA 90032; [email protected]. This manuscript was submitted November 7, 2013; revisions were requested February 15, 2014; the manuscript was accepted for publication April 5, 2014. Copyright Ó 0000 by American Journal of Health Promotion, Inc. 0890-1171/00/$5.00 þ 0 DOI: 10.4278/ajhp.131107-QUAN-567
American Journal of Health Promotion
Month 0000, Vol. 0, No. 0
0
Psychological stress and related health disorders are an increasing problem in the United States. According to a report by the American Psychological Association, 44% of U.S. adults have experienced an increase in psychological stress in the past 5 years.14 Stress severity is also a growing issue. In a survey of a nationally representative sample conducted in 2013, 20% of U.S. adults reported that the stress they regularly experienced was extreme in nature.15 The health burden of stress on the American population is reflected in the ailments that are reported in health care settings: an estimated 60% to 80% of primary care medical visits in this country involve stress-related health complaints.16 It is clear that psychological stress is a substantial and growing problem among the U.S. adult population that requires mitigation strategies. Stress reduction programs can decrease the risk for many diseases and improve the outcomes of many stressrelated illnesses.16–19 Despite this, many people rely on maladaptive stress-coping strategies, such as engaging in sedentary activities, engaging in unhealthful eating behaviors, and consuming alcohol, which do little to help with long-term stress management.14 One factor that may contribute to the lack of adaptive stress management skills among the general population is poor access to stress management counseling. A recent study that surveyed physicians in the United States reported low rates of stress reduction and management counseling for patients by primary care physicians.20 Lack of time during primary care visits and an overburdened health care system have been cited as reasons for deficits in such care.16,20,21 The lack of stress reduction counseling in primary medical care highlights the need for stress management skills training programs that people can readily access in their communities, which are transportable across diverse populations. Large-scale and community-based programs for stress management hold potential for answering this unmet need. One approach to helping people more wisely manage stress that can be applied in the community setting is
0
American Journal of Health Promotion
experience. The classes lay the foundation for students to understand basic principles of mindfulness, to develop a personal meditation practice, and to apply the principles in their daily lives on an ongoing basis. MAPs I classes were open to the general public for a fee comparable to similar courses being offered in the community, with reduced fee–waivers and work-exchange opportunities available. Classes were advertised by using flyers, e-mails, and announcements in local newspapers, magazines, and Web sites. Individuals self-enrolled in MAPs I without interference by the research team. All individuals aged 18 years and older who attended the first MAPs I class in a 6-week series between fall 2008 and spring 2009 were invited to complete a confidential survey before and after the intervention whereby no identifying information was collected. Individuals younger than 18 years could enroll in the class but were not permitted to participate in the study. Before the start of the first class, participants provided consent and completed the baseline questionnaire measures. On the last day of the MAPs course, participants completed the final set of questionnaires, provided demographic information, and completed a course evaluation. Participation was entirely voluntary, and participants could choose not to complete any question. Anonymous identifiers were used to match the presurveys and postsurveys. This study can be conceptualized as a naturalistic field evaluation of the MAPs I curriculum, as it is delivered day-to-day in the community by self-enrolled residents. Study protocols were approved by the UCLA Institutional Review Board (No. 07-308A). Self-reported demographic data collected at postintervention (available for 78% of the sample) indicated that approximately 84% were Caucasian, 8% were Asian, 6% were Latino, and approximately 1% were mixed race; 74% were female. The participants reported a median income of equal to or less than $150,000, with a range from under $25,000 to over $250,000.
t s r
i F
e n i
l n
o
mindfulness training. Mindfulness training uses various exercises to cultivate a quality of consciousness that is characterized by a nonjudgmental, moment-to-moment attentiveness to experiences, thoughts, and emotions.22–25 The skills cultivated through mindfulness training help override and perhaps even replace maladaptive, and largely reactive, responses to stressors.24 Over time and with sustained mindfulness practice, the enhanced awareness of present-moment experience cultivated through mindfulness training enables more deliberate, conscious responses to stressful challenges, thus facilitating more adaptive selfregulation, stress reduction, and emotion management.24,26,27 These characteristics of mindfulness training make it a promising intervention focus for stress-related health promotion and disease prevention in the general community. Mindfulness training for stress reduction has been successfully implemented in clinical populations through formal programs such as Mindfulness-Based Stress Reduction.25,28–30 However, less is known about how mindfulness training can be used for stress reduction in the broader community and for the promotion of public health. The current study implemented a mindfulness program for stress reduction in a community setting. The objective of the study was to determine if a community-based mindfulness training program might help reduce psychological stress levels in a community-based sample of adults who were novices to mindfulness training. We hypothesized that participation in the mindfulness program would result in improved mindfulness, improved self-compassion, and reduced perceived stress from baseline to postintervention.
METHODS Sample and Design The sample consisted of N ¼ 127 adults (mean age ¼ 45.3 years, SD ¼ 14.6 years) attending Mindful Awareness Practices (MAPs) for Daily Living I offered at the UCLA Mindful Awareness Research Center located in a large urban Los Angeles community. MAPs I is the introductory level course offered to individuals without prior meditation
Self-Report Measures Mindfulness. Participants self-reported dispositional mindfulness levels by using the Kentucky Inventory of Mind-
Month 0000, Vol. 0, No. 0
fulness Skills (KIMS),31 a 39-item questionnaire that taps four distinct mindfulness-related skills or facets: Acting with Awareness (e.g., ‘‘When I do things, my mind wanders off and I’m easily distracted’’), Observing (e.g., ‘‘I notice changes in my body, such as whether my breathing slows down or speeds up’’), Describing (e.g., ‘‘I’m good at finding words to describe my feelings’’), and Nonjudgmental Acceptance (e.g., ‘‘I tell myself that I shouldn’t be feeling the way I’m feeling’’). Items are rated from 1 ¼ never or very rarely true to 5 ¼ very often or always true, and scores are computed by averaging the items within each facet. The items can also be combined to form a composite score of mindfulness, with higher scores indicating higher total mindfulness. The KIMS mean score, as well as the four facet scores, showed high internal consistency reliability estimates at baseline and postintervention (all Cronbach a . .80). Self-Compassion. Participants reported on their self-compassion by using the Self-Compassion Scale (SCS),32 a 26item scale that assesses six distinct skills or facets of self-compassion: Self-Kindness (e.g., ‘‘I try to be understanding and patient toward aspects of my personality I don’t like’’), Self-Judgment (e.g., ‘‘I’m disapproving and judgmental about my own flaws and inadequacies’’), Common Humanity (e.g., ‘‘I try to see my failings as part of the human condition’’), Isolation (e.g., ‘‘When I think about my inadequacies it tends to make me feel more separate and cut off from the rest of the world’’), Mindfulness (e.g., ‘‘When something painful happens I try to take a balanced view of the situation’’), and Overidentification (e.g., ‘‘When I’m feeling down I tend to obsess and fixate on everything that’s wrong.’’). Items are rated from 1 ¼ almost never to 5 ¼ almost always, and scores are computed by averaging the items within each subscale. The SCS mean score, as well as the six facet scores, showed adequate internal reliability estimates at baseline and postintervention (all Cronbach a . .74).
Table 1 Correlation Coefficients Between Mindfulness, Self-Compassion, and Perceived Stress† Variables 1. 2. 3. 4. 5. 6.
Perceived Stress. Participants also reported on the degree to which they appraised their current life demands as
American Journal of Health Promotion
SD
2
3
4
5
6
3.06 3.41 2.19 1.70 2.65 3.06
0.40 0.38 0.66 0.62 0.67 0.65
0.56**
0.36** 0.17
0.21* 0.39** 0.57**
0.49** 0.28** 0.66** 0.47**
0.22* 0.55** 0.43** 0.65** 0.67** –
t s r
† Coefficients reported are Pearson r. M indicates mean; KIMS, Kentucky Inventory of Mindfulness Skills composite score; PSS, Perceived Stress Scale composite score; and SCS, SelfCompassion Scale composite score. * p , 0.05. ** p , 0.01.
i F
overwhelming, unpredictable, and uncontrollable by using the 10-item Perceived Stress Scale (PSS).33 Items are rated from 1 ¼ never to 5 ¼ very often (e.g., ‘‘In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?’’). A total score is calculated by taking the mean of all items, with higher scores representing higher perceived stress (Cronbach a ¼ .87 [baseline]; Cronbach a ¼ .87 [postintervention]).
e n i
l n
o
Baseline KIMS Postintervention KIMS Baseline PSS Postintervention PSS Baseline SCS Postintervention SCS
M
Intervention Mindful Awareness Practices for Daily Living I. MAPs I is a weekly, 2-hour, sixsession, group-based course in mindfulness meditation, which is available to all residents in the community. An experienced mindfulness teacher with 20 years of mindfulness meditation practice and teaching delivered the MAPs program curriculum to participants. Session titles by week include (1) Introduction to Mindfulness, (2) Listening, Embodiment, and Obstacles, (3) Working With Pain, (4) Difficult Emotions and Cultivating Positive Emotions, (5) Thoughts and Mindful Interactions, and (6) Loving Kindness and Class Wrap-up. Mindfulness exercises embedded in the curriculum include mindful sitting meditation, mindful eating, appreciation meditation, loving-kindness meditation, and mindful movement such as mindful walking. Participants engage in an average of 20 to 30 minutes of mindful experiential practice during each class. Participants are also
provided with a textbook on mindfulness,34 accompanied by a meditation compact disc for recommended daily practice at home. Mindfulness practice is assigned as homework beginning with 5 minutes daily and advancing to 20 minutes daily by the program’s end.
RESULTS Descriptive Statistics As shown in Table 1, before and after mindfulness training, both selfreported mindfulness and self-compassion scores were negatively correlated with perceived stress. Moreover, mindfulness and self-compassion scores showed strong positive correlations with each other before and after mindfulness training.
MAPS I Training Improvements in Mindfulness, Self-Compassion, and Perceived Stress. Our primary hypothesis was that participation in MAPs I training would result in improvements in self-reported mindfulness, self-compassion, and reductions in perceived stress from baseline to postintervention. As shown in Table 2, this hypothesis was confirmed through a series of pairedsample t-tests. All three variables (and their individual facet scores) showed significant improvement at immediate postintervention. Effect size estimates (range ¼ .33–.90) were of moderate to large magnitude.35 Differences in postintervention outcomes by sex and ethnicity were minimal: women had higher Observe scores (t ¼ 2.80, p ¼
Month 0000, Vol. 0, No. 0
0
Table 2 Paired t-Tests Examining Change in Self-Reported Mindfulness, Self-Compassion, and Perceived Stress From Baseline to Postintervention† Pre-MAPs
Post-MAPs
Variables
M
SD
M
SD
d
KIMS Observe KIMS Describe KIMS Act with Awareness KIMS Acceptance KIMS Composite Score SCS Self-Kindness SCS Self-Judgment SCS Common Humanity SCS Isolation SCS Mindfulness SCS Overidentified SCS Composite Score PSS
3.24 3.55 2.66 2.82 3.06 2.69 3.60 2.85 3.40 3.02 3.57 2.65 2.20
0.56 0.69 0.54 0.74 0.40 0.75 0.83 0.84 0.93 0.75 0.84 0.67 0.66
3.66 3.77 2.97 3.23 3.41 3.05 3.09 3.14 2.88 3.31 3.11 3.06 1.70
0.52 0.65 0.48 0.73 0.38 0.73 0.80 0.82 0.93 0.67 0.80 0.65 0.62
0.78* 0.33* 0.61* 0.56* 0.90* 0.49* 0.63* 0.35* 0.56* 0.41* 0.56* 0.62* 0.78*
e n i
l n
Exploratory Analyses Predicting Postintervention Change in Perceived Stress. We next examined whether change in selfreported mindfulness or self-compassion scores from baseline to postintervention predicted change in perceived stress at postintervention. First, we calculated standardized residual change scores by fitting a regression model in which baseline mindfulness composite scores predicted postintervention mindfulness composite scores. A separate regression analysis was fit to compute change scores for the selfcompassion composite scores. We next fit a hierarchical regression analysis predicting change in perceived stress from baseline to postintervention. Step 1 included baseline perceived stress, while residual change scores for mindfulness and self-compassion were both entered in step 2. As shown in Table 3, change in self-compassion (b ¼.44, t ¼ 5.06, p , .001), but not mindfulness (b ¼ .04, t ¼ .41, p ¼ .68), predicted postintervention perceived stress, above and beyond baseline perceived stress.
o
0
American Journal of Health Promotion
DISCUSSION
t s r
i F
† MAPs indicates Mindful Awareness Practices; M, mean; KIMS, Kentucky Inventory of Mindfulness Skills; SCS, Self-Compassion Scale; and PSS, Perceived Stress Scale. * p , 0.001.
.006), Describe scores (t ¼ 2.81, p ¼ .006), and Common Humanity scores (t ¼ 1.95, p ¼ .054) at postintervention than men. No other differences emerged between groups at postintervention.
possible mechanism for the improvement of stress through self-compassion. It appears from the variables assessed that it was not direct improvements in mindfulness skills that led to decreased stress, but improvements in self-compassion brought about through mindfulness training. Prior cross-sectional work has also shown that, compared to mindfulness, self-compassion accounted for 10 times more unique variance in anxiety, depression, and quality of life in a large sample of distressed adults.36 From a practice perspective, mindfulness training directly cultivates self-compassion through its effect on enhancing personal insight into the linkages between sensations, emotions, thoughts, and habitual reactions that produce psychological suffering. Thus, mindfulness training may reduce stress by helping people cultivate adaptive compassionate attitudes and approaches to internal and external sources of stress, which ultimately mitigates the impact of these stressors on psychological well-being. Future studies exploring the role of mindfulness on health and well-being should also include direct assessments of selfcompassion so that the effectiveness of each on stress reduction can be evaluated. Findings from this study parallel previous research but also provide new insights into the use of communitybased mindfulness training for gener-
Our results demonstrate that mindfulness, self-compassion, and perceived stress significantly changed in the direction of improvement after completion of a community-based mindfulness training program offered to all residents of the general community who sought out the program to deal with a variety of life challenges. The effect sizes for changes in overall mindfulness, self-compassion, and perceived stress were moderate to large (d ¼ .62 for SCS, d ¼ .78 for PSS, d ¼ .90 for KIMS). At postintervention, lower perceived stress scores were correlated with higher total mindfulness scores and higher self-compassion scores. Further, we found that postintervention perceived stress scores were predicted by changes in self-compassion. This is the first published study to examine the effects of the MAPS I program on psychological stress in a sample of adult community residents. Overall, the results from this study suggest that an accessible, communitybased mindfulness program can help people perceive less stress in day-to-day life. The findings from this study provide insight into the impact of mindfulness training on psychological stress and a
Table 3 Hierarchical Regression Analysis Predicting Postintervention Perceived Stress From Change in Self-Reported Mindfulness and Self-Compassion Scores†
Variables Baseline PSS Changes in KIMS Changes in SCS R2 DR2
Step 1
Step 2
b 0.57*
b 0.58* 0.04 0.44* 0.54 0.21*
0.33
† PSS indicates Perceived Stress Scale; KIMS, Kentucky Inventory of Mindfulness Skills; and SCS, Self-Compassion Scale. * p , 0.001.
Month 0000, Vol. 0, No. 0
alized health promotion and disease prevention. The effectiveness of mindfulness training for stress reduction is well supported by previous research. Mindfulness programs have been shown to reduce stress in various populations, including patients diagnosed with cancer,37 organ transplant recipients,38 patients with chronic illnesses,39 and specific healthy populations including students and medical professionals.40 The effectiveness of community-based interventions for stress-related health problems is also supported by a small number of studies. Community-based programs have been used to improve acute posttraumatic stress,41 hypertension,42 and depression and anxiety.43 Mindfulness training programs reported in the research literature44,45 are most often housed within medical centers not geared toward community accessibility. Findings from our study only begin to fill the gaps in the research regarding general stress management in the community, and provide support for the use of community-based mindfulness skills training as an approach to meet the needs of stress reduction at the general community level. Some limitations of this study warrant discussion. The sample was composed predominantly of Caucasian and female participants, which could limit the generalizability of the findings. Assessments were conducted at preintervention and postintervention, so long-term maintenance of change in the outcomes cannot be determined here. Given the naturalistic field evaluation intent of the study, no comparison group was available; therefore, threats to internal validity are plausible such as history, maturation, testing, regression to the mean, and group support. Future research should determine if community-based mindfulness training programs are effective for stress management and reduction in more diverse populations. Comparison groups in future studies could be included to determine the comparative efficacy of mindfulness training to other stress reduction strategies offered in the community, such as fitness and social support programs, as well as to control for other nonspecific effects of social support on stress reduction.
CONCLUSIONS Findings from this study suggest that mindfulness, self-compassion, and stress can improve through mindfulness training in a community-based program using a field evaluation approach. The moderate to large effect sizes for changes in mindfulness, selfcompassion, and perceived stress suggest that mindfulness training might be a promising intervention for producing effects that are relevant for community-based disease prevention
o
American Journal of Health Promotion
t s r
Acknowledgments
The authors are grateful to Diana Winston for codevelopment and teaching of the MAPs Curriculum. This research study was supported by the Pettit Foundation and postprogram support by NIH/NCI (T32CA009492) to Ms O’Reilly. This research was conducted at the UCLA Mindful Awareness Research Center (www.marc.ucla.edu).
i F
SO WHAT? Implications for Health Promotion Practitioners and Researchers
What is already known on this topic? Evidence from mindfulness-based interventions in clinical and subclinical (those who suffer from symptoms of stress but are not characterized by or sampled on the basis of a diagnosed psychological or physiological disorder) populations indicates that mindfulness training can lead to improvements in psychological stress. However, little is known about the effects of mindfulness when routinely deployed in a community context for the general population. Accessible, communitybased strategies for stress reduction are needed to reduce the burden of psychological stress on individuals residing in the urban community. What does this article add? This study found that mindfulness training implemented through a community-based program led to self-reported reductions in perceived stress. Changes in self-compassion predicted postintervention perceived stress, suggesting that improved selfcompassion is a potential mechanism for the impact of mindfulness training on perceived stress. What are the implications for health promotion practice or research? The findings from this study demonstrate that mindfulness training through a community-based program such as MAPs can have a beneficial impact on perceived psychological stress in an urban population. Mindfulness training may offer a promising approach for general public health promotion and disease prevention efforts by its function to enhance self-compassion and alleviate stress.
e n i
l n
and health promotion efforts. Considering the broad health implications of persistent psychological stress, designing accessible interventions that are available in the community, which help individuals to successfully reduce stress, is critical for maintaining health and wellness in the face of our everdemanding lifestyles.
References
1. McEwen BS. Protective and damaging effects of stress mediators. N Engl J Med. 1998;338:171–179. 2. McEwen BS, Stellar E. Stress and the individual: mechanisms leading to disease. Arch Intern Med. 1993;153:2093–2101. 3. Brotman DJ, Golden SH, Wittstein IS. The cardiovascular toll of stress. Lancet. 2007; 370(9592):1089–1100. 4. Torpy JM, Lynm C, Glass RM. JAMA patient page. Chronic stress and the heart. JAMA. 2007;298:1722. 5. Kiecolt-Glaser JK, McGuire L, Robles TF, Glaser R. Emotions, morbidity, and mortality: new perspectives from psychoneuroimmunology. Annu Rev Psychol. 2002;53:83–107. 6. Ehlert U, Gaab J, Heinrichs M. Psychoneuroendocrinological contributions to the etiology of depression, posttraumatic stress disorder, and stress-related bodily disorders: the role of the hypothalamus, pituitary, adrenal axis. Biol Psychol. 2001;57:141–152. 7. Cohen S, Janicki-Deverts D, Miller GE. Psychological stress and disease. JAMA. 2007;298:1685–1687. 8. Dallman MF, Pecoraro N, Akana SF, et al. Chronic stress and obesity: a new view of comfort food. Proc Natl Acad Sci U S A. 2003;100:11696–11701. 9. Belmaker RH, Agam G. Major depressive disorder. New Engl J Med. 2008;358:55–68. 10. Hampton T. Chronic stress and depression. JAMA. 2012;308:444. 11. Pittenger C, Duman RS. Stress, depression, and neuroplasticity: a convergence of mechanisms. Neuropsychopharmacology. 2007;33:88–109. 12. Roozendaal B, McEwen BS, Chattarji S. Stress, memory and the amygdala. Nat Rev Neurosci. 2009;10:423–433. 13. Lupien SJ, McEwen BS, Gunnar MR, Heim C. Effects of stress throughout the lifespan on the brain, behaviour and cognition. Nat Rev Neurosci. 2009;10:434–445. 14. American Psychological Association. Stress in America: Our Health at Risk, 2012. Washington, DC: American Psychological Association; 2012.
Month 0000, Vol. 0, No. 0
0
15. American Psychological Association. Stress in America: Missing the Health Care Connection. Washington, DC: American Psychological Association; 2013. 16. Avey H, Matheny KB, Robbins A, Jacobson TA. Health care providers’ training, perceptions, and practices regarding stress and health outcomes. J Natl Med Assoc. 2003;95:833, 836–845. 17. Gerber M, Puhse U. Review article: do ¨ exercise and fitness protect against stressinduced health complaints: a review of the literature. Scand J Public Health. 2009;37: 801–819. 18. Cabral P, Meyer HB, Ames D. Effectiveness of yoga therapy as a complementary treatment for major psychiatric disorders: a meta-analysis. Prim Care Companion CNS Disord. 2011;13:1–12. 19. Rainforth MV, Schneider RH, Nidich SI, et al. Stress reduction programs in patients with elevated blood pressure: a systematic review and meta-analysis. Curr Hypertens Rep. 2007;9:520–528. 20. Nerurkar A, Bitton A, Davis RB, Phillips RS, Yeh G. When physicians counsel about stress: results of a national study. JAMA Intern Med. 2013;173:76–77. 21. Chen LM, Farwell WR, Jha AK. Primary care visit duration and quality: does good care take longer: effect of duration and quality on primary care. Arch Intern Med. 2009;169:1866–1872. 22. Brown KW, Ryan RM. The benefits of being present: mindfulness and its role in psychological well-being. J Pers Soc Psychol. 2003;84:822–848. 23. Daubenmier J, Lin J, Blackburn E, et al. Changes in stress, eating, and metabolic factors are related to changes in telomerase activity in a randomized mindfulness intervention pilot study. Psychoneuroendocrinology. 2012;37:917–928. 24. Grossman P, Niemann L, Schmidt S, Walach H. Mindfulness-based stress reduction and health benefits: a metaanalysis. J Psychosom Res. 2004;57:35–43.
0
American Journal of Health Promotion
38.
39.
40.
trial: the effect of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients. Psychosom Med. 2000; 62:613–622. Gross CR, Kreitzer MJ, Russas V, et al. Mindfulness meditation to reduce symptoms after organ transplant: a pilot study. Adv Mind Body Med. 2004;20:20–29. Simpson J, Mapel T. An investigation into the health benefits of mindfulnessbased stress reduction (MBSR) for people living with a range of chronic physical illnesses in new Zealand. N Z Med J. 2011; 124(1338):68–75. Chiesa A, Serretti A. Mindfulness-based stress reduction for stress management in healthy people: a review and meta-analysis. J Altern Complement Med. 2009;15:593–600. Macy RD, Behar L, Paulson R, et al. Community-based, acute posttraumatic stress management: a description and evaluation of a psychosocial-intervention continuum. Harv Rev Psychiatry. 2004;12: 217–228. Schneider RH, Staggers F, Alexander CN, et al. A randomized controlled trial of stress reduction for hypertension in older African Americans. Hypertension. 1995;26: 820–827. Sharplin GR, Jones SBW, Hancock B, et al. Mindfulness-based cognitive therapy: an efficacious community-based group intervention for depression and anxiety in a sample of cancer patients. Med J Aust. 2010;193(5 suppl):S79–S82. Goyal M, Singh S, Sibinga EMS, et al. Meditation programs for psychological stress and well-being: A systematic review and meta-analysis. JAMA Intern Med. 2014; 174:357–368. Black DS, Milam J, Sussman S. Sittingmeditation interventions among youth: A review of treatment efficacy. Pediatrics. 2009;124:e532–e541.
t s r
i F
e n i
l n
o
25. Ludwig DS, Kabat-Zinn J. Mindfulness in medicine. JAMA. 2008;300:1350–1352. 26. Bishop SR. What do we really know about mindfulness-based stress reduction? Psychosom Med. 2002;64:71–83. 27. Reibel DK, Greeson JM, Brainard GC, Rosenzweig S. Mindfulness-based stress reduction and health-related quality of life in a heterogeneous patient population. Gen Hosp Psychiatry. 2001;23:183–192. 28. Kabat-Zinn J. Full Catastrophe Living: The Program of the Stress Reduction Clinic at the University of Massachusetts Medical Center. New York, NY: Delta; 1990. 29. Kabat-Zinn J. Mindfulness-based interventions in context: past, present, and future. Clin Psychol. 2003;10:144–156. 30. Kabat-Zinn J. An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results. Gen Hosp Psychiatry. 1982;4:33–47. 31. Baer RA, Smith GT, Allen KB. Assessment of mindfulness by self-report: the Kentucky inventory of mindfulness skills. Assessment. 2004;11:191–206. 32. Neff KD. The development and validation of a scale to measure self-compassion. Self Identity. 2003;2:223–250. 33. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24:385–396. 34. Smalley SL, Winston D. Fully Present: The Science, Art, and Practice of Mindfulness. Philadelphia, Pa: Da Capo Press; 2010. 35. Cohen J. Statistical Power Analysis for the Behavioral Sciencies. Hillsdale, NJ: Routledge; 1988. 36. Van Dam NT, Sheppard SC, Forsyth JP, Earleywine M. Self-compassion is a better predictor than mindfulness of symptom severity and quality of life in mixed anxiety and depression. J Anxiety Disord. 2011;25: 123–130. 37. Speca M, Carlson LE, Goodey E, Angen M. A randomized, wait-list controlled clinical
41.
42.
43.
44.
45.
Month 0000, Vol. 0, No. 0
