Study Characteristics
Of the 13 articles, 10 were published in the past decade. There were no articles prior to 2007 that specifically addressed MBSR programs or MBIs in low socio-economic settings. Most (n = 11) of the studies were conducted in the United States (USA) (Abercrombie et al., 2007; Bermudez et al., 2013; Bhambhani & Gallo, 2022; Burstein et al., 2020; Dutton et al., 2013; Felder et al., 2018; Gallegos et al., 2015; Jacobs et al., 2017; Spears et al., 2017; Szanton et al., 2011; Zhang & Emory, 2015). Only two studies were conducted elsewhere: one in Canada (Hick & Furlotte, 2010) and one in Belgium (Van der Gucht et al., 2015). The large number of studies conducted in the USA is consistent with current findings that since 1996, 90% of all research on mindfulness has been conducted in USA and the United Kingdon (UK), with no significant research in other regions (Baminiwatta & Solangaarachchi, 2021).
Methodologies
Of the 13 articles, two were randomized controlled trials (Dutton et al., 2013; Zhang & Emory, 2015), two had a pre-posttest design (Jacobs et al., 2017; Van der Gucht et al., 2015), four were qualitative (Bermudez et al., 2013; Hick & Furlotte, 2010; Spears et al., 2017; Szanton et al., 2011) and five did not report study design.
Population
Seven studies focused solely on women (Abercrombie et al., 2007; Bermudez et al., 2013; Dutton et al., 2013; Felder et al., 2018; Gallegos et al., 2015; Szanton et al., 2011; Zhang & Emory, 2015). Two studies only included pregnant women (Felder et al., 2018; Zhang & Emory, 2015). Four studies did not mention gender. One article included elderly participants, between 60 and 90-years-old (Szanton et al., 2011). Two articles targeted populations that had experienced trauma (Dutton et al., 2013; Gallegos et al., 2015).
Sampling Process
Five articles did not describe sampling or inclusion/exclusion criteria for selecting participants (Bhambhani & Gallo, 2022; Jacobs et al., 2017; Szanton et al., 2017; Zhang & Emory, 2015; Bermudez et al., 2013). In the remaining eight studies, four mentioned inclusion and exclusion criteria but did not report sampling (Felder et al., 2018; Spears et al., 2017; Gallegos et al., 2015; Abercrombie et al., 2007), one reported using volunteers (van der Gucht et al., 2015); two used convenience sampling (Burstein et al., 2020; Hick & Furlotte, 2010) and one used randomized sampling (Dutton et al., 2013). Only three articles mentioned a recruitment strategy (Burstein et al., 2020; Gallegos et al., 2015; Hick & Furlotte, 2010).
Sample Size
The sample sizes varied considerably. Three studies had a sample size of over 100, ranging from 106 to 256 participants (Burstein et al., 2020; Dutton, et al., 2018). The other 10 studies had sample sizes ranging from 10 to 56 participants. In terms of attrition, three studies reported attrition between 30% and 60% (Felder et al., 2018; Gallegos et al., 2015; Dutton et al., 2013;), while four reported attrition between 60% and 84% (van der Gucht et al., 2015; Zhang & Emory, 2015; Hick & Furlotte, 2010; Abercrombie et al, 2007). The remaining six studies did not mention attrition.
Research Tools
Various research tools were used in these studies. The only tools that were used in more than one study were the Self-Compassion Scale (n = 2), the Pittsburgh Sleep Quality Index (n = 2), the Perceived Stress Scale (n = 3), the Five Facet Mindfulness Questionnaire (n = 2) and focus groups (n = 3). Five studies used demographic questionnaires (Felder et al., 2018; Jacobs et al., 2017; Spears et al., 2017; Gallegos et al., 2015). The studies that were concerned with acceptability and feasibility all used different tests (Jacobs et al., 2017; Gallegos et al., 2015; Dutton et al., 2013; Hick & Furlotte, 2010). Two studies measured physiological biomarkers: one for cortisol (Zhang et al., 2021) and one reported immunological data (Gallegos et al., 2015).
Context
The articles reported varied contexts in which the interventions were offered. Two studies did not mention the actual context, other than the town where the study was conducted (Burstein et al., 2020; Hick & Furlotte, 2010). Two programs were run in shelters for women, one particularly for those experiencing domestic violence and homelessness (Bermudez et al., 2013; Dutton et al., 2013). Six interventions were run either in clinics or hospitals, including a women’s clinic and a university hospital (Bhambhani et al., 2022; Felder et al., 2018; Spears et al., 2017; Gallegos et al., 2015; Zhang & Emory, 2015; Abercrombie et al., 2007). One intervention was conducted amongst residents at a low-income senior housing facility (Szanton et al., 2011); one was run amongst paraprofessionals working within a pre- and primary school setting for children demonstrating emotional, behavioral and academic risk (Jacbos et al., 2017); and one was offered to visitors to public social and health facilities (van der Gucht et al., 2015). Only five studies reported the actual geographic location of the intervention (Bhambhani & Gallo, 2022; Burstein et al., 2020; van der Gucht et al., 2015; Szanton et al., 2011; Hick & Furlotte, 2010).
Facilitator Training and Experience
Five articles did not mention the training and experience of facilitators. One article mentioned that the facilitator had a well-established personal practice and was experienced in adapting mindfulness practices for high-risk youth yet did not refer to any training in mindfulness facilitation (Jacobs et al., 2017). Another article described the facilitators demographically and academically but did not mention experience or qualifications in mindfulness (Bhambhani & Gallo, 2022). Two studies described facilitators who were experienced and had received mindfulness facilitator training – one facilitator had online training in the program (Zhang & Emory, 2015) and, the other facilitator had weekly supervision in the program (Felder et al., 2018). Three studies specifically mentioned the qualifications of the facilitators, including that all facilitators were experienced (Dutton et al., 2013; Gallegos et al., 2015; Van der Gucht et al., 2015). One study was specifically concerned with dispositional mindfulness and therefore did not require any facilitators to lead the intervention (Burstein et al., 2020).
Mechanisms
Due to the decades-long history of MBSR and the substantial body of research related to its application in a variety of contexts and settings, MBSR may be viewed as the “gold standard” against which other MBIs might be assessed (Crane et al., 2017). Alongside this foundational structure, we need to consider how MBSR might be adapted to different situations to meet ethical obligations of providing culturally sensitive service delivery (Woidneck et al., 2012). Table 1 indicates how the 13 articles included in this review retained the core principles of the MBSR “gold standard” (the “warp”) while adapting the interventions to be more context-sensitive (the “weft”) (Crane et al., 2017). One study was a straight MBSR (Gallegos et al., 2015), seven were adapted MBSRs (Bhambhani & Gallo, 2022; van der Gucht et al., 2015; Bermudez et al., 2013; Dutton et al., 2011; Szanton et al., 2011; Hick & Furlotte, 2010; Abercrombie et al., 2007); three were MBIs that differed from MBSR on certain key elements (Felder et al., 2018; Jacobs et al., 2017; Zhang & Emory, 2015); one article did not describe an intervention (Burstein et al., 2020), and one article tested the effects of two 2-hour focus groups on wellbeing (Spears et al., 2017).
Table 1
Comparison of reviewed articles on mindfulness-based interventions (MBI) with the practice of mindfulness-based stress reduction (MBSR) (Crane et al., 2017)
Author | Description | Number of weeks | Session length | Retreat | Additional themes | Adapted structure | Additional comments | Facilitator training |
Bermudez et al. (2013) | Adapted MBSR | 10 | Not specified | Yes, after session 8 | Loving-kindness; music; mindful planning | Slight variation in session progression | Not specified | Not specified |
Abercrombie et al. (2007) | Adapted MBSR | 6 | 2 hours | Not specified | Related to the context of the program, i.e pap smears | Reduced number of sessions and shorter sessions | Not specified | Not specified |
Bhambhani and Gallo (2022) | Adapted MBSR | 16 | 1 hour | Not specified | Trauma-informed cultural humility approach | 16 weekly sessions divided into four modules Shortened sessions and practices Language adapted | More directive than MBSR in terms of inquiry, homework review and psychoeducation | Facilitated by the researchers Qualifications not mentioned |
Zhang and Emory (2015) | MBI - Mindf. Motherhood | 8 | Not specified | Not specified | Not specified | Not specified | Factors that contribute to treatment barriers need to be considered Need to improve strategies encouraging participation and adherence, including cultural relevance | Facilitated by an advanced PhD student in clinical psychology Online training in the intervention Experience and qualifications not given |
Van der Gucht et al. (2015) | Adapted MBSR | 8 | 90 minutes | Not specified | Psychoeducation | Shortened sessions | Possibly increase participation rates by using financial incentives | Trained mindfulness facilitators (n = 2): clinical psychologist (n = 1) and social worker (n = 1) Qualification not discussed Both experienced |
Burstein et al. (2020) | No intervention, questionnaire only | Not applicable | Not applicable | Not applicable | Not applicable | Not applicable | Not specified | Not applicable |
Szanton et al. (2011) | Focus group study of adapted MBSR | 8 | Shortened sessions | Not specified | Not specified | More sitting practice - less mindful movement and walking Shortened sessions | Not specified | Not specified |
Spears et al. (2017) | 120-minute focus group after two 5min practices | Not applicable | 2 hours | Not applicable | Reflection on mindfulness and specific practices, including appeal, relevance, language, acceptability, and perceived feasibility | Short practices (n = 2) on mindful breathing and body scan | Suggestions offered regarding how practice might be integrated into daily life; preparing participants for the possibility of experiencing discomfort; creating an atmosphere of safety and support | Not specified |
Hick and Furlotte (2010) | Adapted MBSR – integrated with Radical Mindfulness Training (RMT) | Not specified | Not specified | Not specified | Focus on sociological education to understand the roots of poverty | Not specified | Radical mindfulness training with core elements of MBSR. engages participants at the personal, interpersonal, and structural levels. | Not specified |
Jacobs et al. (2017) | MBI | 6 sessions over 8 weeks | 90 minutes | Not specified | Muscle relaxation / no mindful eating | Restructured MBSR; 6 weeks instead of 8; shorter sessions; and shorter practices averaging 5 minutes in duration | Not specified | Facilitator not specifically trained in mindfulness but had 6 years personal mindfulness experience and experience in adapting mindfulness practices for high-risk youth in urban communities. |
Dutton et al. (2013) | Adapted MBSR | 10 sessions | 90 minutes | 5 hours - between session 8 and 9 | Additional mindfulness practices including loving-kindness and mindfulness listening exercises | Pre-program orientation sessions with the MBSR instructor; changing the beginning of each session; changing the sequence of sessions; shorter and fewer sessions; logistical support for participants; and ensuring voluntary participation | Minimally adapted MBSR - more accessible to the population. | A trained and experienced female psychiatric nurse (MSN) with teacher-level training in MBSR |
Gallegos et al. (2015) | MBSR | 8 | 2 hours plus | 4 hours | Nil reported | Nil reported | Program was run according to the MBSR manual developed by the University of Mass. Center for Mindfulness | Program delivered by experienced teacher with advanced training |
Felder et al. (2018) | MBI | 8 | 2 hours | Not specified | Mindful eating specifically | Similar to MBSR i.e. 8 x 2 hour sessions | Aim was to reduce overeating as a response to stress | Facilitated by two experienced mindfulness teachers who received weekly supervision |
Outcomes
Of the 13 articles reviewed, one article reported that participants believed that mindfulness practice might improve their mental and physical health, but did not report clear outcomes (Spears et al., 2017). The outcomes of the remaining 12 articles are reported in Table 2. We analyzed the outcomes deductively by aligning the outcomes with mindfulness theory. Mindfulness practice involves understanding our lived experiences by recognizing the nature of our thoughts (cognitive processes), emotions and physical sensations (physiological elements), particularly when experiencing stress. In addition to the outcomes described in Table 2, one article reported that modifying the MBI in particular ways improved outcomes for people facing extreme poverty and associated difficulties (Hick & Furlotte, 2010). Zhang and Emory (2015) reported that attending more mindfulness sessions reduced depressive symptoms one-month post-intervention. Two articles reported on the acceptability of their initiatives (Jacobs et al., 2017; Szanton et al., 2011), one article reported on feasibility (Hick & Furlotte, 2010), and two articles reported on both acceptability and feasibility (Dutton et al., 2013; Gallegos et al., 2015).
Table 2
Outcomes reported in the reviewed articles describing mindfulness-based interventions (MBI) for wellbeing in low socioeconomic settings.
Category | Outcomes | Abercrombie et al. (2007) | Bermudez et al. (2013) | Bhambhani and Gallo (2022) | Burstein et al. (2020) | Felder et al. (2018) | Gallegos et al. (2015) | Hick and Furlotte (2010) | Jacobs et al. (2017) | Szanton et al. (2011) | Van der Gucht et al. (2015) | Zhang and Emory (2015) | Total |
Physiological | Improved health / pain management | X | | X | | | | | | | | | 2 |
Improved sleep quality | | | | | | | | X | | | | 1 |
Cognitive | Improved focus | | | X | | | | | | | | | 1 |
Increased awareness / self-awareness | | X | X | X | | | | | | | | 3 |
Increased self-kindness / self-compassion | | X | | | | | X | | | | | 2 |
Improved self-advocacy/ assertive communication / capacity to affect changes to challenges | | X | X | | | | X | | | | | 3 |
Increased capacity to overcome personal trauma | | X | | | | | | | | | | 1 |
Improved anger management | | X | X | | | | | | X | | | 3 |
Improved coping skills relating to depression and medical procedures | | | | | | | | | X | | | 1 |
Improved eating habits | | | X | | | | | | | | | 1 |
Improved overall subjective wellbeing | | | | X | | | X | | | X | | 3 |
Decreased reactivity | | | | X | | | | | | X | | 2 |
Decreased over-generalization | | | | | | | | | | X | | 1 |
Decreased self-judgement / judgement | | | X | X | | | X | | | | | 3 |
Emotional | Improved emotional regulation | | X | | | | X | | | | | | 2 |
Improved emotional health | | | X | | | | | | | | | 1 |
Increased serenity | | | X | | | | | | | | | 1 |
Decreased emotional dysregulation | | | | | | X | | | | | | 1 |
Decreased emotional exhaustion | | | | | | | | X | | | | 1 |
Decreased depression | | | X | | | X | | | | X | X | 4 |
Decreased anxiety | | | | | | X | | | | X | | 2 |
Interpersonal | Increased capacity for socialization/ connection | | X | | | | | X | | | | | 2 |
Improved quality of relationships/ interpersonal functioning | | X | X | | | | | | | | | 2 |
Decreased isolation | | | | | | | X | | | | | 1 |
Stress | Decreased stress | X | | | | | X | | | | X | | 3 |
Decreased perceived stress | | | | | X | | | X | | | | 2 |
Decreased post-traumatic stress symptoms | | | | | | X | | | | | | 1 |
Mindfulness | Increased mindfulness (capacity for awareness and description of experiences as well as non-judgement and non-reactivity) | | | | | | X | | | | X | | 2 |
Recommendations to improve MBI outcomes in terms of acceptability, accessibility and feasibility
The articles reviewed recommended several improvements for MBIs in the future. The specific barriers to participation in MBIs were noted as time conflicts, financial constraints (Abercrombie et al., 2007; Spears et al., 2017), lack of childcare, transport, work scheduling, health problems, death of a family member (Van der Gucht et al., 2015), unsafe neighborhoods and unsafe housing (Spears et al., 2017).
Suggestions for reducing attrition varied depending on the population’s cultural practices, values and needs – particularly for women whose lives tend to be more unpredictable and demanding (Abercrombie et al., 2007). Women might be encouraged to participate if there is support in terms of meals, childcare, transport and weekly reminders, as well as financial incentives and offering classes at multiple times during the week (Abercrombie et al., 2007; Dutton et al., 2013; Gallegos et al., 2015; Van der Gucht et al., 2015; Zhang & Emory, 2015).
Interventions could be adapted to increase accessibility by delivering the program in the population’s mother-tongue or offering translations and using examples from participants’ lives (Abercrombie et al., 2007; Bhambhani & Gallo, 2022; Burstein et al., 2020). Community members could be involved in various ways, such as training community members to be facilitators (Dutton et al., 2013). This would ensure that facilitators are from a similar cultural background to the participants, especially if they share similar trauma (Bermudez et al., 2013; Bhambhani & Gallo, 2022; Burstein et al., 2020; Zhang & Emory, 2015). Facilitators should be appropriately trained in MBI delivery (Dutton et al., 2013). Participation could also be improved if there were fewer and shorter sessions without compromising positive outcomes (Hick & Furlotte, 2010; Jacobs et al., 2017). MBIs could be integrated into home practice in such a way that it does not increase daily pressure and stress (Dutton et al., 2013). Mobile applications may also increase participation in MBIs (Burstein et al., 2020).
One-on-one pre-interventions sessions could help to clarify participants’ understanding and expectations of the program (Dutton et al., 2013). Participants and facilitators should continuously engage to address concerns and facilitate involvement (Dutton et al., 2013; Spears et al., 2017).
Ten articles recommended further research, including replicating existing studies with optimal retention (Zhang & Emory, 2015); examining the biological and bio-behavioral parameters of health, stress reactivity, and resilience (Burstein et al., 2020; Gallegos et al., 2015; Van der Gucht et al., 2015); investigating the dose of practice on response (Jacobs et al., 2017); and exploring the relationship between mindfulness and physical health in low-income populations, including amongst older adults (Szanton et al., 2011).
Several studies suggested larger samples and the use of control groups to confirm the findings of pilot studies, as well as randomized control and longitudinal studies (Dutton et al., 2013; Hick & Furlotte, 2010). Studies should ensure bias-free assessment by including larger assessment batteries (Jacobs et al., 2017).