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Interventions based on meditation and mindfulness techniques have been shown to reduce stress and increase psychological well-being in a wide variety of populations. Self-administrated Internet-based mindfulness training programs have the potential to be a convenient, cost-effective, easily disseminated, and accessible alternative to group-based programs.
This randomized controlled pilot trial with 90 university students in Stockholm, Sweden, explored the feasibility, usability, acceptability, and outcomes of an 8-week Internet-based mindfulness training program.
Participants were randomly assigned to either an intervention (n=46) or an active control condition (n=44). Intervention participants were invited to an Internet-based 8-week mindfulness program, and control participants were invited to an Internet-based 4-week expressive writing program. The programs were automated apart from weekly reminders via email. Main outcomes in pre- and postassessments were psychological well-being and depression symptoms. To assess the participant’s experiences, those completing the full programs were asked to fill out an assessment questionnaire and 8 of the participants were interviewed using a semistructured interview guide. Descriptive and inferential statistics, as well as content analysis, were performed.
In the mindfulness program, 28 out of 46 students (60%) completed the first week and 18 out of 46 (39%) completed the full program. In the expressive writing program, 35 out of 44 students (80%) completed the first week and 31 out of 44 (70%) completed the full program. There was no statistically significantly stronger intervention effect for the mindfulness intervention compared to the active control intervention. Those completing the mindfulness group reported high satisfaction with the program. Most of those interviewed were satisfied with the layout and technique and with the support provided by the study coordinators. More frequent contact with study coordinators was suggested as a way to improve program adherence and completion. Most participants considered the program to be meaningful and helpful but also challenging. The flexibility in performing the exercises at a suitable time and place was appreciated. A major difficulty was, however, finding enough time to practice.
The program was usable, acceptable, and showed potential for increasing psychological well-being for those completing it. However, additional modification of the program might be needed to increase retention and compliance.
ClinicalTrials.gov NCT02062762; https://clinicaltrials.gov/ct2/show/NCT0206276 (Archived by WebCite at http://www.webcitation.org/6j9I5SGJ4)
Structured group-based meditation interventions, such as the Mindfulness-Based Stress Reduction (MBSR) program [
The Internet provides an opportunity to deliver evidence-based psychosocial programs to a broader range of individuals and a possibility to disseminate interventions targeting stress and stress-related problems to large groups [
Several studies have explored the experiences of Internet-based interventions among users, although few of them have investigated participant perceptions of specific mindfulness-based programs. In one randomized controlled trial (RCT) assessing the feasibility of an Internet-based mindfulness program for stress management in the Unites States, participants were asked to complete a questionnaire about overall feedback on the intervention and reasons for early study or program termination [
This randomized controlled pilot trial examined the feasibility, usability, acceptability, and outcomes of a newly developed 8-week Internet-based mindfulness training program among Swedish students. Feasibility was examined by determining the degree to which participants were engaged in and completed the program. Usability and acceptability were assessed using postintervention questionnaires and semistructured interviews of experiences at completion of the program. Outcomes were examined by comparing pre- and postassessments of psychological well-being and depression symptoms both within the intervention group and between those participating in the mindfulness training program and those randomized to an active control condition. This broad approach of evaluation aims to expand the knowledge about the potential of Internet-based self-administrated mindfulness-based programs to improve mental health status.
Study participants were recruited between December 2013 and March 2014 by advertising at different university campuses in Stockholm, Sweden. The study was open to students aged 18 years and older with access to a computer and an email address. Students interested in participation phoned or sent an email to the study coordinators to receive additional information about the study design. Participants were randomized to either the intervention group (Internet-based mindfulness training program) or an active control group (Internet-based expressive writing program) on a rolling basis using a random sequence of numbers. One of the authors generated the sequence of numbers using SPSS statistical analysis software (IBM Corp) and another author enrolled and assigned participants in the order they were recruited. All participants in both groups were asked to fill out a questionnaire before and after the program and complete weekly assessments. Participants who did not respond to the weekly assessments were reminded by email. The completion of a week’s training was not time-limited, but the next set of program material was only made available after the participant completed the previous training and assessment. Those who did not respond to the reminder or did not fill out the weekly assessments marking continued participation were not asked to give a reason for discontinuation or noncompliance. All participants completing the Internet-based programs were compensated in an amount of SEK 500 (about $54).
The mindfulness training program developed for this study was a modified version of the group-based mindfulness program developed by Jon Kabat-Zinn [
Program content.
Topic of lecture | Formal exercises | Informal exercises | |
Week 1 | Mindfulness: benefits to quality of life and health | Introduction of: |
Introduction of: |
Week 2 | Cultivation of mindful attitudes | Continued practice of introduced exercises | Continued practice of introduced exercises |
Week 3 | The desire to keep or avoid | Introduction of: |
Introduction of: |
Week 4 | Mindfulness and stress | Continued practice of introduced exercises | Continued practice of introduced exercises |
Week 5 | Relations and social context | Introduction of: |
Continued practice of introduced exercises |
Week 6 | Automatic thoughts | Continued practice of introduced exercises | Introduction of: |
Week 7 | Sleep and Mindfulness | Encouragement to train without audio files and experiment with different combinations of exercises | Introduction of: |
Week 8 | No lecture | Encouragement to again use audio files and choose preferred exercises | Continued practice of introduced exercises |
The main departures in the content of our self-administrated program from MBSR as described in the standards of practice from the University of Massachusetts Medical School [
Participants in the Internet-based expressive writing program were asked to write about stressor-related emotions and thoughts for 20 minutes on 4 occasions spread out over approximately 4 weeks. This procedure is drawn from work by Pennebaker and colleagues and has been tested across dozens of RCTs [
Participants were asked to complete a baseline questionnaire which included questions on age, gender, level of education, and living situation. This was done in connection to the obtaining of baseline measures of the outcome variables.
Psychological Well-Being is a questionnaire measuring 6 dimensions: environmental mastery, self-acceptance, positive relations with others, purpose in life, personal growth, and autonomy. It has been extensively used and has shown acceptable factor structure and validity [
The Center for Epidemiologic Studies Depression Scale is a 20-item scale measuring depression symptoms in nonpsychiatric populations [
After each week, the participants in the mindfulness intervention group were asked to answer questions about how much time they had spent on exercises during the previous week. Participants in both groups were also asked to respond to a number of questions assessing potential mediators of intervention effect: mindfulness skills after weeks 2, 4, 6, and 8 and positive/negative affect after weeks 1, 3, 5, and 7. For the analyses in this paper, the time and frequency of practice is reported, but no analyses of the mediation was performed.
At the postassessment follow-up, respondents were asked to answer 7 questions on a scale of 1 to 9, where 1 indicates “not at all” and 9 indicates “very,” to evaluate their overall experiences of the programs. The questions were based on research into factors considered to be important for participation in Internet-based programs (ie, how well the intervention is received and perceived by users) [
Baseline characteristics of the sample, stratified by experimental group, were examined to ensure that key variables were evenly distributed by randomization using Student
To get information about participant perceptions of the mindfulness training program, telephone interviews were conducted with a small number of participants shortly after program completion. The focus of the interviews was the participant experience of the techniques, information, instructions, and exercises, as well as the perceived support received from the study coordinators. The first students who completed the mindfulness program were asked to participate in an interview. One of the study coordinators (PK) conducted all interviews using a semistructured guide with open-ended questions along with probing statements. The interview guide reflected issues that have previously been shown to influence participant perceptions of Internet-based programs (eg, if the program was easy to use [
Qualitative content analysis was used to analyze the interview data [
Example of analysis.
Meaning unit | Condensed meaning unit | Code | Subcategory | Category |
I think that the layout was very good. The way you clicked and came forward. You click on one side and then you move on in a logical sequence. And then all the exercises, and after that the questions before starting the next week. | The user perceived the platform as easy to navigate. | The platform was perceived as easy to navigate. | Program-related facilitators | Usability |
All procedures were performed in accordance with the ethical standards of the institutional and/or national research committees, the 1964 Helsinki Declaration and its later amendments, or comparable ethical standards. Informed consent was obtained from all the individual participants included in the study. The study was approved by the Ethics Committee of the Karolinska Institutet (No. 2010/1407-31).
A total of 104 students contacted the study coordinators requesting more information about the study or expressing an interest in participating with 90 students deciding to participate. Some students left the trial before completing the baseline questionnaire and initiating the program (6 were randomized to the mindfulness training program and 8 to the control condition). A flowchart showing enrollment and number of participants completing each week of the programs is presented in
Of those randomized to the mindfulness training program (n=46), 40 individuals (30 women and 10 men) began the program and 39% (18/40, 16 women and 2 men) completed it. A total of 22 participants (14 women and 8 men) did not complete the postintervention questionnaire. The median age of the completers was 25 years (range 18-45), and the mean age was 29 years. Corresponding figures for the 22 participants who did not complete all 8 weeks of the mindfulness program was 22 years (range 19-37) and 24 years, respectively. On average, participants practiced 3.6 days per week. Even though the reason for participants to leave the program was not systematically assessed, half of those who terminated the program before completion stated an explanation for leaving by email to the study coordinator. Of these, 9 mentioned lack of time, one had technical problems with the computer at home, and one participant referred to changed circumstances. Of the 18 who completed the mindfulness program, 8 (7 women and 1 man) were interviewed.
Of the 44 students randomized to the expressive writing intervention, 36 (26 women and 10 men) began the program and 31 (70%, 23 women and 8 men) completed it. A total of 5 who started the program (3 women and 2 men,) did not complete the postintervention questionnaire.
Those who completed the programs were significantly older than those who did not (
Flowchart showing enrollment and number of participants at each phase of the study.
There were no statistically significant differences between the intervention and control groups concerning baseline scores on psychological well-being (
The MANOVA analyses with baseline and follow-up on psychological well-being and depression symptoms showed no significant time × group (intervention vs active comparison) interaction (
Results of within-group
Intervention condition (n=40) |
Active control condition (n=36) |
||||
Psychological well-being | |||||
Baseline | 60.0 (8.7) | 62.7 (13.0) | |||
Postintervention follow-up | 62.0 (10.1) | .04 | 64.1 (11.8) | .11 | |
Depression symptoms | |||||
Baseline | 20.3 (10.4) | 18.7 (9.9) | |||
Postintervention follow-up | 18.2 (9.6) | .08 | 17.5 (9.8) | .30 |
The results from the postintervention questionnaire are presented in
Participant responses to the postintervention questionnaire.
Not at all |
Some |
A lot |
|||
.11 | |||||
Mindful | 0 (0) | 7 (39) | 11 (61) | ||
Control | 4 (13) | 16 (52) | 11 (36) | ||
.21 | |||||
Mindful | 1 (6) | 13 (72) | 4 (22) | ||
Control | 8 (26) | 18 (58) | 5 (16) | ||
.35 | |||||
Mindful | 1 (6) | 8 (44) | 9 (50) | ||
Control | 6 (19) | 14 (45) | 11 (36) | ||
.93 | |||||
Mindful | 8 (44) | 7 (39) | 3 (17) | ||
Control | 14 (45) | 13 (42) | 4 (13) | ||
<.001 | |||||
Mindful | 1 (6) | 5 (28) | 12 (67) | ||
Control | 16 (52) | 15 (48) | 0 (0) | ||
.28 | |||||
Mindful | 0 (0) | 9 (50) | 9 (50) | ||
Control | 4 (13) | 13 (42) | 14 (45) | ||
Mindful | 0 (0) | 6 (33) | 12 (67) | ||
Control | — | — | — |
Two main categories and seven subcategories were identified in the interview material. In the category
The salient topics in this subcategory are positive or satisfactory experiences of technique, web layout, information, questionnaires, and support from study coordinators. Most of the participants were satisfied with the technique and web layout and reported no problems navigating and downloading files.
I think that the layout was very good, the way you clicked and came forward. You click on one side and then you move on in a logical sequence. And then all the exercises. And after that, the questions before starting the next week.
I had no problems with the technology and stuff, with audio files and so on.
Most of the participants perceived the content of the information texts and audio files as informative and enjoyable. The amount of information was also regarded as suitable. The differing lengths of the guiding audio files were appreciated.
I thought it was a very good way to get some background information every week. I thought the texts were just the right length. The material was interesting to read.
Opinions regarding the weekly questionnaires varied among those interviewed. Some participants made both positive and negative statements about them. Positive statements concerned, for example, clarity and suitable scales. The communication with study coordinators and the weekly reminders were perceived as positive and supportive by several of the participants.
Yes, it has been great. The weeks go so damn fast, so without the emails, I probably would have forgotten about it altogether.
Participants felt that they got answers quickly when they emailed questions to the study coordinators. The weekly reminders made it easier for them to remember to practice.
The salient topics in this subcategory are negative or unsatisfactory experiences of web layout, information, and questionnaires. Although most of the participants expressed satisfaction with the information content of the program, some highlighted deficiencies in the texts, focusing on spelling, grammar, and lengthy sentences.
Yes, there was a typo here and there and, yes, maybe there was a sentence structure or two, which I couldn’t understand. But there were some typos, I reacted to them [. . .] there were unfinished sentences that were difficult to understand.
The organization of audio files in the weekly modules was perceived as confusing by one of the respondents. In addition, some participants had complaints about the questionnaires. Most of these were about repetitive questions and difficulties in finding a suitable answer.
This category comprises explicit proposals for improvements of the program mentioned by the interviewees. Some participants suggested improvements regarding the interaction with study coordinators and technical and layout issues. One of the respondents said that more emails reminding participants to exercise might facilitate completion of the program. Another suggestion was to arrange a meeting with the study coordinators and other participants at the beginning of the program in order to facilitate participation in and completion of the program. It was also suggested that a phone call from the study coordinators at the beginning of the program would increase the completion rate. Other suggestions were related to technical improvements, such as providing access to a special smartphone app where the participants could log their training. A reorganization of the audio files was proposed as was the provision of some kind of bank with questions from other participants, with related answers from the study coordinators.
The topics included in this subcategory are about circumstances connected to the participants’ personal situations that contributed to facilitating implementation of the program. Some of them were related to attitudes or motivation, like curiosity and personal interest, and others to more practical or technical conditions, like having the opportunity to download files onto a phone and listen to them on the way to work.
Well, I have a positive attitude towards it because I have practiced mindfulness before, privately on my own, in different ways [. . .] I am very curious and interested.
The topics in this subcategory are about circumstances connected to the participants’ personal situations that impeded implementation of the program. The absolutely dominant topic was that participants had difficulties in getting the training to fit into their daily lives and in finding the time to practice.
During that time, I was preparing for an exam and it was a bit hard and challenging to find the time to perform these exercises, and it was a little more stressful than I thought. I needed time, and more time, and everything.
At the beginning I was more careful to ensure that it was 45 minutes every day, but then sometimes it became only 30 minutes. Then there were some days when my schedule didn’t work out, and I didn’t have time for anything at all.
A couple of other issues were also mentioned as impeding the training. One of the participants had technical problems with the computer at home, and another lived together with a partner in a small flat and therefore had difficulties finding an undisturbed environment to practice.
Statements reflecting satisfaction that are not closely related to the technical and pedagogic functioning of the program were categorized as positive experiences. A prominent topic in this subcategory is appreciation of the opportunity to choose between exercises and time to practice.
The advantage is that it has been great to be able to do it just when you feel like it, that you don’t need to fit in with a time.
A number of participants also mentioned positive experiences from the training itself, like getting help to relax and calm down. The facts that participation was anonymous and that the exercises were performed at home were also mentioned as positive, as well as the experience of being in a permissive condition.
Statements reflecting dissatisfaction not closely related to the technical and pedagogic functioning of the program were categorized as negative experiences. The negative experiences reported were to a large extent the stress the participants felt when they tried to find time to practice with the intended duration and frequency.
What I do think is that I have felt a little stress that there have been so many times when we've had, so to speak, . . . when it has been expected that you should do these exercises. It's been something that I thought, what can I say, was a bit stressful.
Some participants found it stressful to plan for the training on their own. Somewhat related to the issue of planning was a statement regarding difficulties in choosing between different exercises in the program. Lack of contact with other participants was also brought up as a dissatisfying, in contrast to the expressed view that anonymity was a good thing.
This study gave support for the usability and acceptability of our self-administered Internet-based mindfulness training program among those who completed it. Although less than two-fifth of the participants completed the full program and participants practiced less than recommended, a significant increase in psychological well-being was observed. There were, however, no statistically significant differences between the intervention and control group. Most of those completing the program expressed that the program was meaningful and helpful in improving their way of being. The flexibility to perform exercises where and when it was convenient for them was appreciated and overall the program layout was perceived as satisfactory. More frequent contact with the study coordinators and reminders were suggested as ways to help participants to complete the daily exercises and to increase the likelihood of successful completion of the program. A major difficulty for several of the participants was to find enough time to practice. In addition, the majority of the participants perceived the program as challenging.
The fact that no statistically significant differences in outcomes between the mindfulness and expressive writing group was detected could be due to the active condition in the control group and the large drop-out rate in the mindfulness group. A large drop-out rate is often associated with an underestimation of the intervention effect in intention-to-treat analysis using last-observation-carried-forward approach [
The flexibility regarding location and time for training was perceived as positive by participants, in line with earlier research [
Choosing between different exercises and having to plan one’s own training were considered demanding by some of those interviewed. Perhaps some participants might have felt the need for clearer guidance and support in the latter part of the program. Earlier research has shown that participants need support, for example in managing time challenges, when taking part in Internet-based programs [
The participants did not spend the intended amount of time practicing mindfulness in this training program. It is possible that greater improvements in well-being and depression symptoms could have been reached with a higher level of compliance. However, a previous 14-day Internet-based mindfulness-based program encouraging students to practice mindfulness meditation 10 minutes each day resulted in a significant group × time interaction for anxiety/depression symptoms, suggesting that it is possible to achieve improvements in mental states with a rather limited effort. In summary, results from this study suggest that students can benefit from an Internet-based mindfulness training program.
Our study highlights the challenge of developing health-related Internet-based interventions, including mindfulness-based programs, that are sufficiently easy to complete for an intended target group. A way to enhance completion of Internet-based programs might be to use more reminders and make personal contact by phone before program start. Less time-consuming exercises and a shorter program period might also be considered in order to raise the completion rates in these interventions. Acquiring further knowledge about how to develop and deliver such programs is warranted in order to make use of the potential of the Internet in health care and other relevant settings.
Although this study is of great interest because it is one of the first to explore the feasibility and effect of an Internet-based mindfulness intervention, it has several limitations. First, the participants were not required to have a certain level of stress or other psychological symptoms to be included in the study, which may have reduced the ability to detect changes in the outcome measures. A possible absence of stress or distress may also have influenced participant perceptions of the program and their motivation to practice. Perhaps they would had given the program a higher priority in their daily lives if they had felt that they really needed the training. Second, our study did not systematically investigate if the students experienced some negative effects from the mindfulness training. A literature review from 2008 concluded that no negative effects from mindfulness-based interventions have been documented [
Our findings support the usability and acceptability of a self-administered Internet-based mindfulness training program for several participants. The program showed potential for increasing psychological well-being. However, additional modification to the target group might be needed to increase retention and compliance.
multivariate analysis of variance
mindfulness-based stress reduction
randomized controlled trial
standard deviation
The research was supported by the Swedish National Research School of Health Care Science, Karolinska Institutet (3656/2012-225).
Two of the authors (PK and RB) developed the programs.
None declared.
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