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ORIGINAL ARTICLES |
Mindfulness Meditation Consultant (B.R.), New Haven, CT and HIV Prevention Section (D.R.),San Francisco Department of Public Health, San Francisco, CA.
Address correspondence and reprint requests to Beth Roth, MSN, 122 Canner Street, New Haven, CT 06511. E-mail bethroth{at}snet.net
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONCONCLUSIONACKNOWLEDGMENTSREFERENCES |
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MATERIALS AND METHODS: An intervention group of 68 patients (48 Spanish-speaking and 20 English-speaking) completed the SF-36 Health Survey and two additional questions about sleep quality and family harmony before and after completing the 8-week MBSR program. A comparison group of 18 Spanish-speaking patients who received no intervention completed the same questionnaire at the same intervals.
RESULTS: Sixty-six percent of the total intervention group completed the 8-week MBSR program. There was significant comorbidity of medical and mental health diagnoses among the intervention and comparison groups, with no differences in the mean number of diagnoses of the total intervention group, the comparison group, or the Spanish- or English-speaking intervention subgroups. Compared with the comparison group, the intervention group showed statistically significant improvement on five of the eight SF-36 measures, and no improvement on the sleep quality or family harmony items.
CONCLUSIONS: MBSR may be an effective behavioral medicine program for Spanish- and English-speaking inner-city medical patients. Suggestions are given for future research to help clarify the program’s effectiveness for this population.
Key Words: mindfulness, • meditation, • stress reduction, • health-related quality of life, • general health status, • bilingual inner-city population
Abbreviations: MBSR = mindfulness-based stress reduction.
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INTRODUCTION |
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There are now more than 200 MBSR programs at United States health care settings (2). Most of the programs are in large medical centers, teaching hospitals, and health maintenance organizations. Some programs are at university health services, pain management clinics, and alternative health centers. A growing number are offered by physicians and psychotherapists in private practice. Few MBSR programs serve inner city minority populations.
Literature Review
Chronic illness, socioeconomic status, and stress
More than one million Americans have a chronic illness (3), and for many of these individuals, the illness decreases their functioning and quality of life and increases their psychosocial stress. The factors of race, ethnicity, and socioeconomic status, often seen in combination, are associated with, and may be predictors of, health variations in different populations (4). For example, members of minority groups, approximately one-fourth of whom live in poverty, have higher rates of morbidity and mortality than do whites, approximately one-tenth of whom live in poverty, according to the United States Department of Health and Human Services (5,6).
Chronic stress, stress that "lasts for a long time, either because it occurs repeatedly or episodically, continuously, or because it poses severe threats that are not easily adapted or overcome" (7), contributes to the poorer health outcomes among minority groups (7). The stress burden associated with low socioeconomic status consists of a variety of environmental, institutional, and psychological factors, which frequently are found in inner city neighborhoods. These factors include high population density, poor sanitation and living conditions, higher costs for basic goods and services, inadequate nutrition and physical exercise, inferior quality of elementary and high school education, poor employment opportunities, high unemployment and underemployment, high levels of noise, crime and violence, high levels of incarceration and homicide, increased tobacco and alcohol use, lack of health insurance and decreased access to health care with the attendant delay in the detection and diagnosis of disease and the differential management and treatment of illness (4). The subjective experience of racism and discrimination may be an additional important stress that adversely affects physical and mental health (4,7).
The literature shows the overrepresentation of racial minorities in low socioeconomic groups, the adverse effects of low socioeconomic status on health, and the exacerbating relationship of chronic stress to poor health. Stress, which exerts its deleterious effects on health and well being through neural, neuroendocrine, and immune system pathways (7), is not simply the product of a difficult external event. The way a person perceives a difficult event, and the skill with which the individual handles the experience, help determine the degree to which the experience is stressful (1). It follows that successful stress reduction strategies for racial and ethnic minorities could potentially improve their health status.
Mindfulness-based stress reduction and health improvements
MBSR research primarily focuses on symptom reduction after completion of the MBSR program. For the most part, subjects have been working-class and middle-class populations in health care settings. Although most published MBSR studies lack randomized control groups, making definitive conclusions about the effectiveness of the intervention difficult, results to date are promising and suggest the need for more rigorously designed studies.
The following findings provide a representative overview of the effects of the MBSR program. In an uncontrolled study of chronic pain patients whose symptoms had not improved with traditional medical care, completing the MBSR intervention decreased physical pain, mood disturbance, and psychiatric symptomatology (8). A study of chronic pain patients and a comparison group that received the standard medical treatment found significant reductions in pain, symptoms, mood disturbance, and psychological symptomatology, including anxiety and depression, in the intervention group, and no significant improvement in the comparison group (9). Fibromyalgia patients completing the MBSR intervention in both an uncontrolled (10) and a controlled (11) study experienced significant reductions in many of the symptoms associated with this illness. In a controlled study comparing psoriasis patients who received MBSR training via audio tape during ultraviolet phototherapy (UVB) or photochemotherapy (PUVA) to psoriasis patients who received only UVB or PUVA, the experimental group showed significantly more skin clearing (12). In a randomized, controlled, clinical trial of cancer patients with a variety of cancer diagnoses and different stages of illness, patients who completed the MBSR intervention had a 65% reduction in mood disturbances and a 31% reduction in stress symptoms, whereas no improvements were found in the control group (13).
Mindfulness meditation is increasingly integrated into outpatient psychotherapy (14,15). In two uncontrolled studies of patients with anxiety disorders (16, 17), MBSR significantly reduced symptoms of anxiety and panic. In one rigorously designed randomized controlled study of mindfulness-based cognitive therapy (MBCT) with recently recovered depressed patients, participants in the intervention group who had experienced three or more previous episodes of recurrent major depression had approximately half the rate of relapse and recurrence as the control group during the 1-year follow-up (18).
In the area of general health status and quality of life, an uncontrolled, hospital-based study of a middle class heterogeneous patient population investigated the effects of MBSR on both health-related quality of life, and medical and psychological symptomatology, and found significant improvements on all measures postintervention (19).
Only a few studies have explored the effects of MBSR on inner-city minority patient populations. Two uncontrolled studies, one at the Worcester City Campus Program (20), a satellite of the Stress Reduction Clinic at the University of Massachusetts, and the other at the Community Health Center in Meriden, Connecticut (21), found that Spanish- and English-speaking inner-city medical patients who completed the MBSR intervention showed significant reductions in medical and psychological symptoms, and significant improvement in self-esteem.
The present study seeks to deepen the understanding of the changes reported by patients who have completed MBSR programs and focuses on how such a program may affect inner-city patient populations. The study compares the general health status and health-related quality of life among Spanish- and English-speaking inner-city patients before and after completing a MBSR program at the Community Health Center of Meriden, Connecticut.
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MATERIALS AND METHODS |
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The Setting
The Community Health Center of Meriden (CHC/Meriden) is operated by a nonprofit health care agency and is a primary care center in central Connecticut. The Center offers primary care services in medical, dental, and mental health. Most of the population served is Hispanic (64%). The breakdown of other patients is as follows: white (26%), black (8%), Asian (1%), and other (1%). The sources of payment include Medicaid (59%), self-payment (27%), Medicare (8%), private insurance (5%), and City Welfare (1%).
Study Subjects
Most patients in the study were referred to the MBSR program by either their primary care or their mental health providers or other health center staff at CHC/Meriden, or by primary care or mental health providers from the Meriden community; a few came through self-referral, often prompted by word-of-mouth or local media coverage of the MBSR program. Patients were referred for a variety of medical and mental health problems. Most of the patients were coping with the chronic stress associated with low socioeconomic status. Some were also experiencing an acute psychosocial stress, such as bereavement, domestic violence, or the illness, incarceration, or death of a family member.
The intervention group consisted of 68 adult patients. Forty-eight of the patients completed the MBSR program in Spanish, and 20 patients completed it in English. None of the black or white patients in the study spoke Spanish, and thus they were assigned to English-language MBSR groups. Nearly all of the Hispanic patients were monolingual Spanish speakers or spoke very little English, and thus they were assigned to Spanish-language MBSR courses. There were a few bilingual Hispanic patients who were given the choice of participating in English or Spanish language MBSR courses. One patient chose to take the program in English. The other patients chose the Spanish language courses, stating that they would feel more comfortable in a group setting with Hispanic participants.
The comparison group consisted of 18 Spanish-speaking adult patients who also had been referred to the MBSR program. They expressed interest in the program, but were unable to participate for reasons including lack of transportation, lack of childcare, and conflict with new state welfare-mandated work schedules that went into effect after the pre-intervention interview but before the start of the program.
Study Design
The study compared self-reported general health status and health-related quality of life of English- and Spanish-speaking inner-city medical patients before and after completing the MBSR program. The comparison group allowed a comparison between patients who completed the MBSR program and patients who received no intervention. General health status and health-related quality of life was measured by the Short Form 36 (SF-36) and by two separate items, one related to sleep quality and one related to family harmony. The data instruments were completed at patient interviews during the 4 weeks before the start of the MBSR program and within 4 weeks after completion of the program. Interviews were conducted in English or Spanish by the MBSR program instructor and researcher or by an assistant. The patients in the comparison group completed the same questionnaires at the same intervals as the patients in the intervention group. Demographic information was collected at the first interview.
Data Instruments
Demographic information
The demographic information from the intervention and comparison groups documented gender, age, marital status, number of children, employment, public assistance, monthly income and the number of persons supported by this income, and years of formal education.
SF-36
The SF-36 developed by John Ware, and in use since 1990, has been translated into approximately 40 languages and is the most widely used health status survey in the world (25). Designed for use in clinical practice and research, health policy evaluations, and general population surveys, the SF-36 assesses health status and the effectiveness of health care interventions from the patient’s point-of-view. It consists of a multi-item scale that measures eight health concepts: general health, physical functioning, role limitations caused by physical health problems, bodily pain, vitality (energy and fatigue), social functioning, role limitations caused by emotional problems, and general mental health (psychological distress and psychological well-being). Reliability and validity of the SF-36 have been extensively investigated and well documented (26). Because the SF-36 scales correlate significantly and positively with general measures of quality of life, it is recognized as a reliable tool for assessing health-related quality of life (26). Spanish-speaking patients in the intervention and comparison groups were administered the United States Spanish language version 1 of the SF-36 (distributed by The International Quality of Life Assessment Project). Although the Spanish version of the SF-36 has not been as extensively investigated as the original English version, preliminary studies have documented high correlations for both reliability and validity (27,28).
Sleep Quality and Family Harmony
To follow-up on frequent anecdotal comments by patients who completed the MBSR program at CHC/Meriden that they had experienced improvements in sleep quality and family harmony, neither of which the SF-36 measures, both the intervention and comparison groups were asked at presessions and postsessions to assess their sleep quality and family harmony. These items were written by the MBSR program instructor and translated into Spanish by the instructor and assistant.
Although their reliability and validity were not assessed, the wording and response scales of the two questions were consistent with the format of the SF-36. The sleep quality question was: "During the past 4 weeks, how often did you sleep well and wake up feeling refreshed?" The family harmony question was: "In general, how do the people in your family/household get along with each other?"
Data Analysis
Frequency distributions were performed on the demographic data. Paired t tests were used to compare the means of the continuous measure demographic variables. Chi-square analyses were used to compare the proportions of the nominal value demographic variables. Frequency distributions were also performed on patients’ medical and mental health diagnostic information. One-way ANOVA tests were conducted to compare the number of each type of diagnosis in the different groups and subgroups.
Scoring of the SF-36 was performed according to the SF-36 Manual. Repeated measures ANOVA tests were performed on the SF-36 measures and on the additional items that assessed sleep quality and family harmony. A one-way ANOVA was performed on all measures at baseline to compare both the total intervention group and the Spanish-speaking subgroup with the comparison group to determine any initial differences. Two factor repeated-measures ANOVA was used to analyze the pre-intervention and postintervention effects and interaction between group and time on the SF-36 measures and the sleep quality and family harmony items. Two factor repeated-measures ANOVA was also used to compare time and language effects and interaction between time and language for the two intervention subgroups. When a statistically significant intervention effect was found for the two way repeated measures ANOVA, indicating that the time effect was different for the two groups, separate one way repeated measures ANOVAs were performed on each group to see if there was a significant change in the measure from one time to the other. SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were also computed for the total intervention group, the two intervention subgroups, and the comparison group. These scoring algorithms were calculated according to SF-36 scoring instructions (29).
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RESULTS |
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All 18 patients in the comparison group were Hispanic women. Their age range was 23 to 55 years, with a mean of 35.17 years. The median monthly income of the patients in this group was $533. Twelve (67%) patients in the group reported receiving public assistance, one (6%) reported not receiving public assistance, and five (27%) did not respond to the question. The mean number of years of schooling was 9.38 years (SD = 3.48).
The intervention and comparison groups were largely equivalent with respect to demographic variables, although the comparison group was younger than the total intervention group and the intervention subgroups, and a greater number of people were supported by the group members’ monthly income. Full demographic information for the intervention and comparison groups is reported in Table 1.
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Of the 68 patients in the intervention group, 14 (21%) attended all eight sessions of the program. Twenty-two patients (32%) attended seven sessions, 16 patients (24%) attended six sessions, and 16 patients (24%) attended five sessions. Reasons given by patients for missed class sessions included difficulties with transportation and childcare, personal or family illness, inclement weather, family emergencies, and conflicts with medical, social service, or legal appointments.
Data on adherence with meditation practice is available for 53 of the patients (19 English-speaking and 34 Spanish-speaking) in the intervention group. Fifty patients (32 Spanish-speaking and 18 English-speaking) reported postintervention that they were meditating, while two Spanish-speaking patients and one English-speaking patient reported that they were not meditating. See Table 3 for complete information about adherence with meditation practice.
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An additional analysis was performed to assess differences between the Spanish- and English-speaking subgroups. On one SF-36 measure, general health, the average Spanish-speaking scores were significantly lower than the average English-speaking scores ((F=6.86 (1, 66), p= .011). Mental health was the only SF-36 measure that demonstrated a language by time interaction, with the English-speaking subgroup showing more significant improvement than the Spanish-speaking subgroup (F=4.49(1), p= .038). Thus, for seven of the eight SF-36 measures, there was no difference in rate of improvement between the two subgroups. There were also no significant differences on the Physical Component Summary (PCS) or Mental Component Summary (MSC) scales. On the sleep quality item, the English-speaking subgroup had a statistically significant higher rate of response to the intervention (F=5.18 (1, 61), p= .027). On the family harmony item, there were no significant differences between the two subgroups before or after the intervention, and no difference in rate of response to the intervention. See Table 5 for comparison of all scores of the Spanish-speaking and English-speaking intervention subgroups.
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DISCUSSION |
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The 66% completion rate of this study is higher than the 60% completion rates of the two other MBSR studies at bilingual inner city settings (20,21). The current study and these two previous studies use the same definition of program completion and are consistent in number and length of class sessions. These completion rates are lower than the rates of 80 to 90% (9), 85% (13), and 89% (19) found in hospital-based studies of working class and middle class populations. However, the hospital studies used different definitions of program completion and/or contained different numbers and lengths of class sessions, making exact comparison of completion rates difficult. While scant data are available to compare the current study population to other study populations in terms of number of class sessions attended and frequency and duration of home meditation practice, it is noteworthy that 52 (77%) of the program completers attended six or more of the eight class sessions, and 50 (94%) of the 53 patients who provided data on their meditation practice reported a home meditation practice, with 34 (64%) patients indicating that they meditated 4 to 7 days per week.
Now we turn to the results of the SF-36 survey, starting with the measure of general health, one of two SF-36 measures that are equally sensitive to both physical and mental health (the other is vitality) (26). An individual’s rating of his or her general health is among the best predictors of mortality and future use of health care services (30–33). A poor self-perception of general health has been correlated with increases in health care utilization, including hospitalizations, medical visits per year, and prescriptions written per visit (34). The improvement in general health after the MBSR intervention suggests that in addition to improving health and well-being, MBSR may also decrease mortality and use of health care services, thereby contributing to cost containment in health care. This hypothesis is consistent with previous research at the site of the present study, in which completers of the Spanish language MBSR program made significantly fewer health center visits in the year after completion of the program than in the year before the program (24).
We note that although the Spanish- and English-speaking subgroups improved to equivalent degrees on the general health measure, the Spanish-speaking subgroup reported significantly poorer general health than the English-speaking subgroup before and after the intervention. The poorer general health of the Spanish-speaking subgroup may be related to their relatively lower socioeconomic status than the socioeconomic status of the English-speaking subgroup, or it may reflect cultural differences in conception and self-assessment of health.
Physical functioning is one of three SF-36 measures that did not significantly improve after the MBSR intervention. At the same time, there was significant improvement in role-physical, which indicates that even though physical functioning did not improve, patients were still better able to engage in work and other daily activities after the intervention. One possible explanation for this discrepancy is that members of a largely Hispanic, primarily female, inner-city, sedentary population may perceive themselves as unable to engage in more vigorous physical activities that are by cultural custom and personal habit outside the realm of their everyday experience. Alternatively, the lack of improvement in physical functioning may be because of the fact that this measure is least affected by the intervention, or that a change in physical functioning cannot be seen immediately postintervention. In the one previous MBSR study (uncontrolled) that used the SF-36 as an assessment instrument, bivariate analysis found physical functioning to be the measure that showed the least improvement immediately after the MBSR intervention (19).
The second of the 3 SF-36 measures that did not show improvement is bodily pain, a result that is in contrast to several previous MBSR studies. As noted, studies of chronic pain patients (8,9) and fibromyalgia patients (10,11) showed a decrease in physical pain after an MBSR intervention. It is true that the subjects of the present study are general medical patients and not chronic pain patients, but 75% of the patients in the intervention group and 84% of the patients in the comparison group had a diagnosis of chronic pain. Additionally, the MBSR study of general medical patients using the SF-36 also showed improvement in the bodily pain measure (19).
Despite the lack of improvement in bodily pain, improvements in role-physical and social functioning (discussed further) indicate that physical problems were interfering less with the roles and activities of daily life after completion of the MBSR program. This outcome is consistent with the findings of two previous studies in which chronic pain patients who report no decrease in their pain after the MBSR program also show a significant improvement in their ability to cope effectively with the pain, thus indicating that they are experiencing less interference with daily life because of physical pain (9,35). Given the scope and impact of chronic pain as a health care and economic problem, an estimated 30 to 50 million Americans experience chronic physical pain, with the socioeconomic costs of health care expenses, disability, and lost productivity adding up to more than $100 billion annually (36), these findings suggest that further study of the short-term and long-term effectiveness of the MBSR intervention for chronic pain patients of different socioeconomic groups would be warranted.
The significant improvement in the SF-36 vitality measure is a promising finding. The measure assesses energy level and fatigue, two components of subjective well-being that are sensitive to both physical and emotional health (26). Energy level is considered central to one’s conception and assessment of health, and has been seen as a link between the domains of body, mind, and spirit (37). Although vitality has rarely been quantitatively measured in MBSR research, significant improvement in vitality was found in the previous MBSR study that used the SF-36 (19), and a MBSR study of cancer patients showed an increase in vigor, a related health measure (13).
Social functioning as a health concept extends the assessment of health beyond the individual’s body and mind to include the quantity and quality of social activities and interactions with others. Because most measures of social activity simply ask respondents about the number and frequency of their social contacts and activities (38), and do not ask whether the patients’ activities have been specifically affected by health problems, the results often reflect nonhealth related factors (39). In contrast, the SF-36 specifically asks respondents to indicate the impact of either physical or mental health problems on their social activities.
In the current study, social functioning scores indicate substantial social isolation caused by physical and mental health problems. In the pre-intervention interview, many patients stated that they had no social life. They made such comments as, "I do not work," "I do not go anywhere," or "I do not visit anyone and no one visits me." Some patients said that their only social activities were shopping for food, attending church, or going to medical appointments. Postintervention improvement in social functioning suggests that completion of the MBSR program helped patients to increase their participation in social activities with less interference from physical or emotional problems.
Along with social functioning, role-emotional and mental health are the three SF-36 scales that best measure the mental component of health status (26). The improvement in role-emotional indicates that the patients’ emotional problems were interfering less with the activities of daily life. This occurred even though there was no significant improvement on the mental health measure.
As noted, 81% of the patients in this study had at least one mental health diagnosis. The lack of improvement on mental health contrasts with previous MBSR research that documented improvements in mental health symptoms among patients with anxiety (16,40), depression (18), fibromyalgia (10,11), cancer (13), other medical illnesses (19–21,41), and among generally healthy populations such as college students (42) and premedical and medical students (43). It should be noted that some patients expressed initial hesitation about participating in the MBSR program because they assumed it was a mental health therapy. Once patients understood that MBSR is an educational intervention and not a mental health therapy, they expressed interest in participating and successfully completed the program. Future MBSR research may help clarify whether MBSR improves mental health and/or decreases the degree of interference of mental health problems on social and emotional functioning, and whether it might serve as an effective mental health intervention for patients with certain mental health problems who, for a variety of reasons, are unwilling to participate in traditional mental health therapy.
In regard to sleep quality and family harmony, the finding of no improvement in either is at odds with the frequent positive reports by completers of the MBSR program at the present site and with the improvements that have been described in MBSR literature (1). This discrepancy may be caused by the use of questions that were not standardized validated assessment measures. Given that an estimated 60 million Americans have insomnia annually, with the total direct, indirect, and related costs of insomnia conservatively estimated at $30 to $35 billion annually (44), and the association of low socioeconomic status with insufficient nightly sleep (45), further research seems warranted to assess the effectiveness of MBSR as a preventive and nonpharmacological treatment for insomnia for all patient groups, and specifically as a way to help ameliorate the effects of stress on low socioeconomic populations. The same can be said of family harmony, given the finding of national research that adults who report positive emotional ties to their spouses, other family members, and friends also report fewer health symptoms, fewer chronic health problems, and better subjective health (46).
Limitations and Suggestions for Future Research
The results of this study of an inner city population show improvements in general health and health-related quality of life that have not been documented by previous quantitative MBSR research. While these findings are encouraging, various limitations in the present study indicate that they can be viewed only as preliminary.
A primary limitation in the patient sample is the small size of the intervention and comparison groups. Other limiting features of the sample are that the intervention and comparison groups were self-selected and not randomly assigned, and that the comparison group received no intervention. Additionally, although the intervention and comparison groups were largely equivalent in terms of demographic information and medical and mental health diagnoses, differences in some baseline SF-36 scores suggest they were not entirely comparable.
On the lack of intervention in the comparison group and the self-selection of subjects in both the intervention and comparison groups, it is noteworthy that benefits have been found in MBSR studies with varying degrees of vigor of study design. Studies that compared the MBSR intervention group to randomly assigned wait list control groups that did not receive an intervention found improvement in mood and decrease in stress among cancer patients (13) and decrease of psychological distress among a nonclinical population of medical students (43). In randomized controlled studies with active control groups, the MBSR intervention was superior to traditional treatment for psoriasis (12) and superior to conventional treatment for relapsed clinically depressed patients (18). In nonrandomly assigned controlled studies the MBSR intervention was more effective than traditional treatment for chronic pain (9) and superior to participation in a seminar in complementary medicine for improvement in mood and decrease in stress among a nonclinical population of medical students (47).
Several other limitations should be noted. Because the Spanish- and English-speaking intervention subgroups had some different mean scores, it is possible that these language subgroups responded to the MBSR program differently. And as with any group psychosocial intervention, factors other than the intervention may have contributed to reported health improvements. Such factors include patient expectation, rapport with the instructor, and the social support inherent in a group intervention in which patients feel free to express themselves in a safe and caring environment.
Because of differences in the literacy levels of patients and difficulties in scheduling patient interviews, variations in questionnaire administration may have affected the study results. Although most patient interviews were conducted orally in person, some patients completed self-administered written surveys, either at the health center or at home, and a few interviews were conducted by telephone. Additionally, in-person interviews were conducted both individually and in small groups. Most study subjects, including the majority of Spanish-speaking subjects, had minimal education and little experience completing health surveys. It was not uncommon for patients to say they did not understand a particular question, and clarification was rarely achieved by simply repeating the question, as instructed by SF-36 administration protocols. In such cases, rephrasing or an elaboration of the question or the response choices was required.
There is also the possibility that patients offered responses that they thought would please the two interviewers, perhaps particularly in the case of the primary researcher, a bilingual, native English-speaking nurse practitioner who was the course instructor and MBSR program director and the primary care provider to 16 (24%) of the 68 patients in the intervention group and to nine (50%) of the patients in the comparison group. The other interviewer was a bilingual, native Spanish-speaking medical assistant who was the assistant to the MBSR program.
Finally, we note that the study assessed only the short-term benefits of participation in an MBSR program. MBSR research has shown long-term benefits of MBSR for chronic pain patients (35) and for patients with anxiety disorders (40) and continued health benefits in a heterogeneous patient population at 1-year follow-up (19).
Future MBSR research with (1) a larger study sample and a randomized control group who receives a non-MBSR group intervention, (2) a more rigorous standardization of questionnaire administration, (3) statistical correlation between degree of adherence to meditation practice and health improvement, and (4) an investigation of long-term effects of participation in a MBSR program would begin to provide answers to many of the questions raised by the present study.
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CONCLUSION |
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ACKNOWLEDGMENTS |
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Received for publication August 8, 2002.
Revision received July 24, 2003.
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