Mindfulness Practice Reduces Hair Cortisol, Anxiety and Perceived Stress in University Workers: Randomized Clinical Trial

Ci a ion: Ghe a di-Dona o, E.C.d.S.; Gimenez, L.B.H.; Fe nandes, M.N.d.F.; Lacchini, R.; Cama go Júnio , E.B.; Díaz-Se ano, K.V.; Melchio , M.; Pé ez, R.G.; Riquelme-Galindo, J.; Reisdo e , E. Mind ulness P ac ice Reduces Hai Co isol, Anxie y and Pe cei ed S ess in Uni e si y Wo ke s: Randomized Clinical T ial. Heal hca e 2023,11, 2875. h ps://doi.o g/ 10.3390/heal hca e11212875 Academic Edi o s: Jespe Dahlgaa d and Jose An onio Mon eal Recei ed: 10 June 2023 Re ised: 19 Oc obe 2023 Accep ed: 30 Oc obe 2023 Published: 31 Oc obe 2023 Copy igh : © 2023 by he au ho s. Licensee MDPI, Basel, Swi ze land. This a icle is an open access a icle dis ibu ed unde he e ms and condi ions o he C ea i e Commons A ibu ion (CC BY) license (h ps:// c ea i ecommons.o g/licenses/by/ 4.0/). heal hca e A icle Mind ulness P ac ice Reduces Hai Co isol, Anxie y and Pe cei ed S ess in Uni e si y Wo ke s: Randomized Clinical T ial Edilaine C is ina da Sil a Ghe a di-Dona o 1,* , La issa Bessani Hidalgo Gimenez 1, Ma ia Ney ian de Fá ima Fe nandes 2, Ricca do Lacchini 1, El on B ás Cama go Júnio 3, K anya Vic o ia Díaz-Se ano 4, Melissa Melchio 4, Raquel Ga cía Pé ez 5, Jo ge Riquelme-Galindo 6 and Emilene Reisdo e 7 1Ribei ão P e o College o Nu sing, Uni e si y o São Paulo, A enida Bandei an es, 3900, Vila Mon e Aleg e, Ribei ão P e o 14040-902, SP, B azil; [email p o ec ed] (L.B.H.G.); [email p o ec ed] (R.L.) 2Nu sing Depa men , Fede al Uni e si y o Ma anhão, A enida P incipal, 100 Residencial Dom A onso Felippe, Impe a iz 65915-240, MA, B azil; [email p o ec ed] 3Facul y o Nu sing, Uni e si y o Rio Ve de, Fazenda Fon es do Sabe , Rio Ve de 75901-970, GO, B azil; el onb asj @uni .edu.b 4School o Den is y o Ribei ão P e o, Uni e si y o São Paulo, A enida do Ca é, s/n, Vila Mon e Aleg e, Ribei ão P e o 14040-904, SP, B azil; [email p o ec ed] (K.V.D.-S.); [email p o ec ed] (M.M.) 5Facul y o Heal h Sciences, Uni e si y o G anada, A enida de la Ilus ación, 18016 G anada, Spain; aquelgp@ug .es 6HLA Vis ahe mosa Hospi al, A enida Denia, 03015 Alican e, Spain; [email p o ec ed] 7 Depa men o P o essional Nu sing and Allied Heal h, Facul y o Nu sing, MacEwan Uni e si y, 104 A enue NW 10700, Edmon on, AB T5J 4S2, Canada; eisdo e [email p o ec ed] *Co espondence: [email p o ec ed] Abs ac : Backg ound: Anxie y and s ess a e common men al heal h condi ions epo ed by uni- e si y wo ke s. P ac ices o mind ulness ep esen one p omising app oach as an e ec i e and easible means o educe s ess, imp o e men al heal h and p omo e well-being; howe e , he e a e no clinical ials ha ha e combined long- e m s ess bioma ke s (hai co isol) and psychome ic assessmen s in a sample o uni e si y wo ke s. Objec i e: This s udy in es iga ed he e ec i eness o a mind ulness-based p og am on long- e m s ess, by measu ing hai co isol concen a ion and pe cei ed s ess and anxie y among wo ke s who we e unde going high le els o s ess. Me hod: We conduc ed a andomized clinical ial a wo k among he employees o a public uni e si y. We compa ed a g oup ha ecei ed he eigh -week mind ulness in e en ion wi h he wai lis g oup who ecei ed no in e en ion. Resul s: A o al o 30 pa icipan s we e included in he s udy, wi h n = 15 subjec s in he in e en ion g oup and n = 15 in he con ol g oup. Hai co isol, pe cei ed s ess and anxie y signi ican ly educed a e he in e en ion compa ed o he con ol g oup, which had no app eciable decline in he measu ed a iables. Conclusion: This clinical ial showed he e ec i eness o a mind ulness p og am on men al heal h psychome ic measu es (pe cei ed s ess and anxie y) and on a long- e m s ess bioma ke (hai co isol). I can be concluded ha an eigh -week mind ulness p og am could be implemen ed as an e ec i e s a egy o educe s ess bioma ke s (hai co isol) as well as pe cei ed s ess and anxie y, imp o ing he men al heal h o uni e si y wo ke s. Keywo ds: mind ulness; hai co isol; s ess; wo ke s; men al heal h 1. In oduc ion Uni e si y wo ke s cons i u e a popula ion wi h signi ican a es o wo k o e load, job dissa is ac ion, occupa ional s ess [ 1 , 2 ], anxie y and he use o non-asse i e coping s a egies such as alcohol abuse [ 3 ]. Pe cei ed s ess is associa ed wi h highe le els o anxie y and poo quali y o li e [ 4 ]. S a egies o managing and educing s ess can also dec ease he occu ence o clinically signi ican anxie y [5]. Heal hca e 2023,11, 2875. h ps://doi.o g/10.3390/heal hca e11212875 h ps://www.mdpi.com/jou nal/heal hca e Heal hca e 2023,11, 2875 2 o 11 The e is subs an ial scien i ic e idence ha mind ulness p ac ices educe subjec i e s ess and inc ease he sense o well-being in wo ke s om di e en sec o s, p o iding pa icula suppo o people su e ing om s ess [ 6 – 9 ]. Mind ulness has been associa ed wi h lowe pe cei ed s ess and highe wo k engagemen in bo h c oss-sec ional and longi udinal analyses [10]. Also, he p ac ice o mind ulness has been epo ed as a s a egy o educe le els o anxie y and imp o e quali y o li e. The e ec s o he p ac ice in educing anxie y symp oms ha e been explained by he impac o a mind ul men al s a e on eapp aisal, wo y and umina ion [ 11 ]. Gi en he main men al heal h p oblems ela ed o s ess among uni e si y wo ke s, a s udy ha a ge s his popula ion using mind ulness p og ams seems highly ele an . Pe sis en o p olonged s ess can ha e dele e ious e ec s on bodily mechanisms, and he e a e many sys ems in he body ha indi idually o collec i ely egula e he le el o s ess, including he hypo halamic-pi ui a y-ad enal axis (HPA axis), au onomic ne ous sys em (ANS) and immune sys em. The HPA axis esponds o s esso s by sec e ing co isol, a ho mone associa ed wi h psychological s ess, making he HPA axis a sys em ha esponds o psychosocial s ess and in e ac s wi h he ANS and immune sys em. Co isol is physiologically measu able h ough analysis o sali a, blood, u ine and hai samples [12]. Se e al s udies ha e used co isol, conside ed a bioma ke o physiological s ess, as a measu e o he e ec o mind ulness-based in e en ions. The accu a e measu emen o co isol in sali a has been epo ed as a me hodological obs acle due o he a iabili y esul ing om he ci cadian hy hm (i.e., diu nal luc ua ion) and he in luence o o al condi ions, among o he ac o s [ 13 ]. Howe e , hai sampling is a me hod conside ed less suscep ible o he me hodological obs acles epo ed in he assessmen o co isol, and i is mo e accu a e o s udies ha aim o e i y he e ec s on physiological ac o s ele an o he neu oendoc ine mechanism ha media es he e ec s o s esso s by egula ing nume ous physiological p ocesses, such as he hypo halamic–pi ui a y–ad enal axis (HPA axis) [ 14 ]. Hai co isol can e lec p olonged s ess exposu e, making i an ideal measu e o assessing ulne able popula ions such as uni e si y wo ke s. Assessmen o pe cei ed s ess is conside ed equally impo an , as he s ess esponse is highly in luenced by he pe son’s pe cep ion o he s esso . The Pe cei ed S ess Scale (PSS) is one o he mos common measu es o assessing global s ess pe cep ions. I measu es he deg ee o which an indi idual pe cei es his/he li e as uncon ollable, unp edic able and o e loaded wi hin he pas mon h [ 15 ]. The PSS is closely linked wi h measu es o psychological s ess and sel - epo ed heal h (dep essi e and physical symp oma ology) [ 16 ]; i is also co ela ed wi h biological ma ke s o s ess and disease [ 17 ]. The Pe cei ed S ess Scale (4-, 10-, and 14-i em e sions), wi h i s psychome ic p ope ies, has been ansla ed in o di e en languages, including B azilian Po uguese [18]. A ecen clinical ial ha e alua ed he e ec o mind ulness-based in e en ions o wo ke s p esen ed esul s o he measu e o pe cei ed s ess in g oups ha unde wen sho - and long- e m mind ulness p og ams, conside ing he po en ial dose– esponse e ec s o mind ulness aining a wo k [ 19 ]. In addi ion, se e al s udies conduc ed wi h p ima y and seconda y eache s also poin ed o he e ec s o mind ulness as an e ec i e s ess managemen s a egy [20–22]. Howe e , no s udies we e ound ha combined biological measu emen and psycho- me ic assessmen in a sample o uni e si y wo ke s. The e o e, i is necessa y o unde ake s udies p o iding e idence o he e ec i eness o he mind ulness p og am, in o de o sup- po he ecommenda ion o he p ac ice o mind ulness o he ca e o uni e si y wo ke s who p esen a high le el o s ess and associa ed anxie y. This s udy in es iga ed he e ec o a mind ulness-based p og am on hai co isol, pe cei ed s ess, mind ulness le els, and anxie y among wo ke s who we e unde going high le els o s ess. Heal hca e 2023,11, 2875 3 o 11 2. Ma e ials and Me hods 2.1. T ial Design A andomized clinical ial (RCT) was conduc ed in acco dance wi h he ecommen- da ions o he Consolida ed S anda ds o Repo ing T ials (CONSORT) [ 23 ]. I was an in e en ion s udy o a con olled, andomized, pa allel, 2-a m clinical ial ype (in e en- ion g oup wi h in e en ion e sus wai lis con ol g oup wi hou ea men ). The s udy was egis e ed in he B azilian Clinical T ials Regis y (ReBec), T ial Regis a ion Numbe (TRN): U1111-1179-7619. The p ocedu es o da a collec ion and analysis we e comple ed in May 2019. 2.2. Pa icipan s and Rec ui men Following app o al by he B azilian E hics Commi ee (p o ocol numbe 58376016.00000. 5393) in acco dance wi h The Code o E hics o he Wo ld Medical Associa ion (Decla a ion o Helsinki), echnical-adminis a i e wo ke s om a Uni e si y in he S a e o São Paulo, B azil we e ec ui ed o ake pa in he s udy (1704 wo ke s). All wo ke s exp essed hei willingness o pa icipa e and signed an in o med consen o m. A eam o esea che s, du ing he pe iod om Ma ch o Decembe 2017, pe sonally app oached all pa icipan s in hei wo k en i onmen and applied a sociodemog aphic ques ionnai e and he Pe cei ed S ess Scale (PSS 14) [ 18 ]. To ensu e da a accu acy, we excluded ce ain wo ke s om he esea ch. Those who we e no ound a hei wo kplace a e h ee a emp s by he esea ch eam (n = 163) o who we e on aca ion (n = 192) o sick lea e (n = 114) du ing he da a collec ion pe iod we e excluded. Incomple e ma e ials (n = 42) and subjec s who did no espond o he ques ionnai es (n = 264) we e excluded om he s udy, composing he losses o he sc eening p ocess. A o al o 929 olun ee s e u ned comple ed da a collec ion. This accoun ed o 54.51% o he o al non- eaching s a popula ion on campus. The selec ed 929 pa icipan s answe ed a sociodemog aphic ques ionnai e and he Pe cei ed S ess Scale (PSS 14) [ 18 ]. Du ing he pe iod om Ma ch o Decembe 2017, he pa icipan s we e pe sonally ap- p oached in hei espec i e wo kplaces by a eam o esea che s and in i ed o pa icipa e. Wo ke s we e eligible o he clinical ial i hey me he c i e ia o high pe cei ed s ess (sco e equal o o g ea e han 23 poin s), as measu ed by PSS 14 [ 18 ]. All wo ke s we e in i ed o pe o m he s ess assessmen . Wo ke s who me one o wo o he ollowing exclusion c i e ia we e no eligible o en ollmen in he s udy: egula medi a ion p ac ice (a leas once a week in he pas 12 mon hs) and engagemen in psycho he apy o men al heal h counseling. These exclusion c i e ia we e used o educe any po en ial con ounding biases ha could a ec he in e en ion’s expec ed e ec . A o al o 281 subjec s me he inclusion and exclusion c i e ia o he s udy and we e andomized o he in e en ion g oup (IG) (pa icipa ed in he 8-week mind ulness p o- g am) o he con ol g oup (CG) (placed on a wai ing lis ). Following he 8-week assessmen pe iod, he wo ke s om he con ol g oup we e gi en he op ion o pa icipa ing in he 8-week mind ulness p og am. 2.3. Randomiza ion and Blinding Sample size calcula ions we e pe o med by a s a is ician and indica ed ha 76 indi- iduals we e needed in he in e en ion (38) and con ol (38) g oups. The sample o he s udy was de e mined u ilizing a con enience me hod based on pa icipan s’ a ailabili y. The numbe o en olled pa icipan s was de ined conside ing hei a ailable ime o commi o he eigh weeks o in e en ion and da a collec ion, as well as he cos -e ec i eness ela ed o human esou ces, in as uc u e and labo a o y es s necessa y o espond o he objec i e o he s udy. Fo he pai ing o he g oups, age, sex and le el o wo k (basic, echnical and highe ) we e conside ed, and pa icipan s we e andomized in a 1:1 a io. Conside ing all he equi emen s men ioned abo e, a ailable pa icipan s (n = 42) we e andomly assigned o ei he an in e en ion g oup (IG = 22) o Heal hca e 2023,11, 2875 4 o 11 ecei e he 8-week mind ulness p og am o o a con ol g oup (CG = 20), which ecei ed no in e en ion and emained on a wai ing lis . The alloca ion lis was gene a ed by a p o essional s a is ician using a andom numbe able, and he sequence was concealed un il he pa icipan s we e assigned. Rec ui men was conduc ed by he esea che , and ins uc o s who conduc ed he in e en ion we e blinded o g oup assignmen . Pa icipan s we e andomly alloca ed o he in e en ion g oup (IG) and con ol g oup (CG), wi hou he op ion o choose hei g oup. Consequen ly, he selec ed pa icipan s we e in i ed o pa icipa e in he second phase o he s udy and p o ided wi h a new in o med consen o m. Da a ega ding he a iables in es iga ed (hai co isol, pe cei ed s ess, symp oms o anxie y and le el o mind ulness) we e collec ed 2 weeks be o e he beginning o he s udy and again a e he end o he s udy (12 weeks a e he i s da a collec ion). This in e en ion could no be masked (pa icipan s knew which g oup hey we e in and ins uc o s knew hey we e pe o ming he in e en ion); hus, o a oid esea ch bias, he ins uc o s who pe o med he in e en ion had no con ac wi h he da a o any app oach o he esea ch- ela ed p ocedu es. The s a is ical p o essional who pe o med andomiza ion and analysis was blinded o he in e en ion. 2.4. Psychome ic Assessmen Pe cei ed s ess was assessed by he Pe cei ed S ess Scale 14-i em e sion (PSS 14). The PSS measu es he deg ee o which indi iduals pe cei e si ua ions as s ess ul [ 18 ]. The o al sco e on he scale can ange om 0 (no s ess) o 56 (ex eme s ess) [15,18]. Anxie y was assessed by he Beck Anxie y In en o y (BAI), c ea ed by Beck e al. (1988) [ 24 ]. I consis s o 21 ques ions abou how he indi idual has been eeling in he las week, exp essed in common anxie y symp oms (such as swea ing and eelings o dis ess). Each ques ion has 4 possible answe s; he one ha mos closely esembles he indi idual’s men al s a e should be ma ked and anges om 0 o 63. Mind ulness was assessed by he Fi e Face Mind ulness Ques ionnai e (FFMQ-BR). This ins umen measu es le els o mind ulness in a mul idimensional way [ 25 ]. Al hough lis ed as i e ace s, he au ho s who alida ed he B azilian e sion ecommend ha he ins umen should be analyzed conside ing se en ace s, namely (1) non-judging o inne expe ience, (2) ac ing wi h awa eness–au opilo , (3) obse ing, (4) desc ibing–posi i e o mula ion, (5) desc ibing–nega i e o mula ion, (6) non- eac i i y o inne expe ience, and (7) ac ing wi h awa eness–dis ac ion [25]. 2.5. Hai Sample o Co isol Measu emen Hai was sampled om he e ex pos e io o wo ke s’ heads. Using s e ile scisso s, a s ip o app oxima ely 1.5 inches (3 cm) o hai was cu a he scalp whe e he e was a hai leng h o a leas 1.5 inches (3 cm). This 3 cm leng h is conside ed o ep esen a 3-mon h e ospec i e measu e o hai co isol, assuming a 1 cm/mon h g ow h a e o hai ; i is a commonly used leng h o sampling [ 26 , 27 ]. Samples we e s o ed in plas ic ials labeled only by ID in a locked oom and a oom empe a u e acco ding o he s o age s anda ds [28] o labo a o y assays. 2.6. Hai P ocessing and Co isol Assay The samples we e sen o assay o he Labo a o y Specialized in Scien i ic Analysis (LEAC) [ 26 , 27 ]. S a ing wi h ∼ 50 mg o hai , wo washes wi h 40 mL o wa e ollowed by wo washes wi h 40 mL o isop opanol on a (o bi al shake ) pla e o a ing a 130 pm o 3 min pe wash we e pe o med. A e each se o washes, he hai samples we e cu in o small pieces using small su gical scisso s. Samples we e pu in o disposable glass scin illa ion ials, and HPLC- g ade me hanol was added a a olume o 100 µ L/mg o hai . Nex , samples we e sonica ed o 30 min ollowed by a 24 h incuba ion pe iod a 50 ◦ C. A e incuba ion, samples we e cen i uged o 30 min a 3000 pm, hen he supe na an was ans e ed in o sepa a e glass Heal hca e 2023,11, 2875 5 o 11 ubes and he me hanol was e apo a ed unde a gen le s eam o ni ogen. Fo samples whe e less han 30 mg o hai was a ailable, smalle olumes o he ex ac we e aliquo ed, co esponding o 5, 10 o 15 mg o hai . Once he me hanol was emo ed, he d y pelle was esuspended in 150–250 µ L o phospha e bu e ed saline (PBS) a pH 7.0. Samples we e o exed o 1 min, ollowed by ano he 30 s un il hey we e well mixed. Fo co isol measu emen in he ex ac s, we used a comme cially a ailable sali a y co isol enzyme- linked immunoso ben assay (ELISA) (Ca . #KAPDB290 (CTS)—Lo 150810—DiaSou ce) acco ding o he manu ac u e ’s ins uc ions. The in a- and in e -assay coe icien o a iance was below 10.3%. 2.7. In e en ion: 8-Week Mind ulness P og am Pa icipan s andomized o he 8-week mind ulness p og am a ended weekly in- pe son 120 min mind ulness-based p ac ice g oup sessions o 8 consecu i e weeks. The ins uc o p og essi ely p omo ed and guided o mal p ac ices wi h he pa icipan s and media ed he exchange o expe iences in each weekly session. Such o mal p ac ices equi e cogni i e e o s, especially a en ion, which g adually e ol e h oughou he eigh weeks, based on di e en pe sonal p ocesses ocused on b ea hing, he body, sensa ions, sounds, hough s and emo ions. In addi ion, he e was a 4 h imme sion session in a la ge space wi h an added na u al a ea ( ees, plan s and g ass loo ). The p og am was led by heal h p o essionals, skilled acili a o s and mind ulness ins uc o s who we e ce i ied expe s in p o iding guidance o lea ning mind ulness p ac ices. Thei expe ise inc eased he chances o success ul a ainmen o a s a e o mind ulness by he pa icipan s [ 29 ]. The p og am consis ed o mind ulness p ac ice aining in a secula con ex , ollowing he oun- da ions o he Mind ulness-Based S ess Reduc ion (MBSR) p og am [ 30 ] and ecommen- da ions om he UK Ne wo k o Mind ulness-Based Teache s Good P ac ice Guidelines o Teaching Mind ulness-based Cou ses [ 31 ]. The ollowing opics we e discussed du ing he 8 sessions: change is easy, b ea hing is na u al, keeping he body conscious, jus be, momen by momen , welcoming emo ions, li ing mind ulness, cul i a ing peace. Du ing ace- o- ace mee ings, pa icipan s we e ins uc ed o pe o m he p ac ices daily a home o he es o each week. Rele an eadings and audio ma e ial we e o e ed o suppo he p ac ice. Audio was made a ailable o pa icipan s in di e se ways: e-mail, Wha sApp ® o Compac Disc (CD), acco ding o he p e e ence indica ed by he pa icipan . Audio iles con ained a guided p ac ice (5-, 10-, 20-, and 30-min body scans and guided medi a ion wi h di e en posi ions and ancho s) eco ded by he mind ulness ins uc o s. A simple habi change was guided each week wi h he pu pose o enhancing he ecogni ion o au oma ic beha io s. A dia y was also o e ed weekly, in which pa icipan s we e encou aged o egis e hei p ac ices a home. The dia y was op ional and no used in he p esen analysis. The main pu pose was o s imula e and o ganize he in eg a ion o p ac ices in he pa icipan s’ daily li es. 2.8. S a is ical App oach To compa e hai co isol, pe cei ed s ess (PSS14), anxie y (BAI) and mind ulness (FFMQ) a p e-in e en ion (T0) and pos -in e en ion (T1) imes in each g oup, he Wilcoxon es o ela ed samples was used. To compa e he di e ences be ween he in e en ion g oup and con ol g oup, he non-pa ame ic Wilcoxon ank sum es was used. The da a we e analyzed using he s a is ical so wa e STATA 11 edi ion. 3. Resul s A o al o 30 olun ee s comple ed he s udy, wi h a loss o 28.6% o pa icipan s who had s a ed he s udy (42): se en om he in e en ion g oup and i e om he wai lis con ol g oup. Follow-up was los due o wi hd awal ( ou pa icipan s epo ed a lack o ime and one pa icipan mo ed o ano he ci y), incomple e in e en ion ( h ee pa icipan s comple ed less han 60% o he in e en ion p og am), and loss o he pos -in e en ion assessmen pe iod ( ou pa icipan s we e una ailable o pos -in e en ion da a collec ion). Heal hca e 2023,11, 2875 6 o 11 The demog aphic da a and hai co isol, pe cei ed s ess, anxie y and mind ulness baseline sco es a e p esen ed by g oup in Table 1. Table 1. Demog aphic cha ac e is ics and le els o co isol, pe cei ed s ess, dep ession and anxie y o s essed uni e si y wo ke s (n = 30). Va iable In e en ion G oup (n = 15) Wai Lis Con ol G oup (n = 15) Age, mean (SD) 41.4 (7.6) 40.5 (8.2) p= 0.865 Educa ion, numbe (%) p= 0.406 High school 4 (26.7) 4 (26.7) G adua e 5 (33.3) 6 (40.0) Pos g adua e 6 (40.0) 5 (33.3) Wo king hou s, mean (SD) 39.7 (1.0) 39.3 (2.6) p= 0.281 Wo king yea s, mean (SD) 14.8 (7.5) 12.3 (7.0) p= 0.639 Le el o mind ulness (FFMQ Sco e) 111.1 (17.7) 115.5 (17.7) p= 0.367 FFMQ-BR: Fi e Face Mind ulness Ques ionnai e (B azilian Ve sion); SD: s anda d de ia ion. No di e ences we e ound in baseline le els o hai co isol o any o he psychological ou come a iables (mind ulness, pe cei ed s ess and anxie y), indica ing ha he andom- iza ion was success ul. The e was no signi ican di e ence in baseline co isol le el o age, educa ion, wo king hou s and wo king yea s (all p> 0.05) (Table 1). Pa icipan s who comple ed he eigh -week mind ulness p og am had hei hai co isol le els signi ican ly educed. The Wilcoxon signed ank es esul s show ha he hai co isol median p esen ed by he in e en ion g oup a e he in e en ion was educed by 3.9 pg/mg (z: 2.953, p: 0.003), while he hai co isol o he con ol g oup showed no signi ican change du ing he s udied pe iod. Also, he psychome ic e alua ion o he pa icipan s who comple ed he mind ulness p og am showed a signi ican dec ease in he median pe cei ed s ess (z: 2.160, p: 0.031) and symp oms o anxie y (z: 2.074, p: 0.038) as well as inc eased le els o mind ulness (z: 1.992, p: 0.046) pos -in e en ion (Table 2). Table 2. Compa ison o he le el o hai co isol, anxie y and pe cei ed s ess in a mind ulness aining in e en ion clinical ial be o e and a e he in e en ion (n = 30). Va iable CG (n = 15) Wilcoxon Signed Rank Tes (p)EG (n = 15) Wilcoxon Signed Rank Tes (p) Wilcoxon Rank Sum Tes Hai co isol T0 median (SD) 15.6 (12.1) z:−0.795, p: 0.426 18.9 (8.7) z: 2.953, p: 0.003 z: 0.892, p: 0.372 T1 median (SD) 18.1 (13.0) 15.0 (5.3) z:−1.805, p: 0.003 Pe cei ed s ess T0 median (SD) 31 (6.2) z: 0.258, p: 0796 32 (8.2) z: 2.160, p: 0.031 z: 0.021, p: 0.983 T1 median (SD) 32 (4.8) 24 (7.8) z:−2.599, p< 0.001 Anxie y T0 median (SD) 11 (8.4) z: 1.082, p: 0.279 10 (6.5) z: 2.074, p: 0.038 z:−0.520, p: 0.603 T1 median (SD) 11 (6.8) 5 (5.3) z:−2.082, p: 0.037 Le el o mind ulness T0 median (SD) 119 (17.5) z:−0.934 p: 0.3502 113 (15.6) z: 1.992 p: 0.046 z: 0.512, p: 0.609 T1 median (SD) 113 (17.7) 127 (15.9) z:−1.848, p: 0.065 Alpha c i e ia = 0.05; CG: Con ol G oup; IG: In e en ion G oup; SD: s anda d de ia ion. Heal hca e 2023,11, 2875 7 o 11 The Wilcoxon ank sum es p esen s a compa ison be ween he con ol and in e en- ion g oups a he median le el o co isol, anxie y, pe cei ed s ess and le el o mind ulness be o e and a e he in e en ion (Table 2). The esul s show ha he in e en ion dec eased he median hai co isol alues (z: − 1.805, p: 0.071) as well as symp oms o pe cei ed s ess (z: − 2.599, p< 0.001) and median anxie y (z: − 2.082, p: 0.037) when compa ed wi h he con ol g oup. The in e en ion g oup also expe ienced an inc ease in he le el o mind ulness (z: − 1.848, p: 0.065). This esul did no occu in he con ol g oup, and no signi ican di e ence was ound be ween he medians a baseline and a e eigh weeks in ha g oup. The esul ega ding he e ec i eness o he mind ulness p og am in ela ion o he con ol g oup, conside ing he e olu ion o he s udy e ec a iables, e ealed ha he in e en ion educed he isk o wo sening hai co isol by 88.8%, pe cei ed s ess by 54.6% and anxie y by 50.0%. The pe cen age o wo sening symp oms was 6.7% in he in e en ion g oup e sus 60.0% in he con ol g oup o hai co isol, 33.3% e sus 77.3% o pe cei ed s ess, and 23% e sus 53.3% o anxie y symp oms (Table 3). Table 3. T ea men e ec i eness o mind ulness p og am in in e en ion and con ol g oups. Va iable In e en ion G oup (n = 15) Con ol G oup (n = 15) T ea men E ec i eness (RRR) Inc eased hai co isol Yes 1 (6.7%) 9 (60.0%) 88.8% No 14 (93.3%) 6 (40.0%) Pe cei ed s ess Yes 5 (33.3%) 11 (77.3%) 54.6% No 10 (66.7%) 4 (26.7%) Anxie y Yes 4 (26.7%) 8 (53.3%) 50.0% No 11 (77.3%) 7 (43.7%) RRR = Rela i e educ ion in he isk o wo sening symp oms. 4. Discussion As a con ex ha gene a es s ess ul si ua ions, he uni e si y en i onmen has d awn he a en ion o he scien i ic communi y, which has sough ways o be e unde s and he di e se ac o s ha in luence his condi ion and o p omo e s a egies ha he uni e si y communi y can employ o imp o e s ess managemen , such as mind ulness in e en ions. Since he li e a u e poin s o he high le els o s ess among uni e si y wo ke s, and in o de o make he e idence mo e obus , ou s udy used ins umen s based on he indi iduals’ pe cep ions and in eg a ed objec i e ways o measu ing s ess le els, which dis inguishes ou wo k om some ea lie s udies. In his s udy, we e alua ed he e ec s o an eigh -week mind ulness p og am on s ess and anxie y compa ed o he esul s o he wai -lis ed con ol g oup ha did no ecei e he in e en ion. Uni e si y wo ke s wi h a high le el o pe cei ed s ess we e e alua ed in bo h he in e en ion and con ol g oups in ela ion o pe cei ed s ess, anxie y and hai co isol le els, he la e being conside ed he mos eliable bioma ke o ch onic s ess and he mos widely used alida ion es [12]. The e was a signi ican e ec o s udy condi ions on changes in hai co isol, pe cei ed s ess, and symp oms o anxie y. Wo ke s had signi ican educ ions in co isol le els a e he in e en ion compa ed wi h hose in he con ol g oup, who had no app eciable decline. Pe cei ed s ess and symp oms o anxie y also educed signi ican ly, which did no occu in he con ol g oup. The inc ease in he sco es o he mind ulness assessmen , which occu ed only in he in e en ion g oup, shows ha he in e en ion was success ul, allowing his e ec o be linked o he se o a iables analyzed. Ou indings a e consis en wi h p e ious s udies ha ha e e alua ed he e ec o a mind ulness p og am on pe cei ed s ess educ ion in o he se ings and Heal hca e 2023,11, 2875 8 o 11 popula ions [ 6 – 9 , 21 ]. Mind ulness-based in e en ions p omo e b ain esponses a he le el o egula ion and eac i i y. Thus, one explana ion o unde s anding he educ ion in s ess le els esul ing om he p ac ice o mind ulness is ha i p omo es he egula ion o eac i i y o s ess in he HPA axis [32]. Rega ding anxie y symp oms, ou esul s a e also in line wi h p e ious e idence, which concluded ha mind ulness-based p og ams a e e ec i e in educing anxie y [33]. One o he o iginal con ibu ions o his s udy was o e alua e psychome ic pa am- e e s (pe cei ed s ess and anxie y) oge he wi h a biological s ess ma ke (capilla y co isol); hus, ega ding he esul s in he e alua ion o hai co isol, he dec ease in his long- e m s ess ma ke was also epo ed in a s udy ca ied ou wi h unde g adua e heal hca e s uden s [ 34 ]. Hai co isol assessmen is an excellen bioma ke o ch onic s ess, co ela ing wi h sali a y co isol le els, which has been co obo a ed by se e al s udies on s ess in di e en popula ions [35]. The co isol a ailable in he hai ep esen s he pe cen age o his bioma ke ha di uses om he blood in o he g owing hai ollicles and is inco po a ed in o he hai wi hou unde going deg ada ion [36,37]. One c ucial disco e y o his s udy is ha he con ol g oup wi nessed a subs an ial ele a ion in co isol le els o e he cou se o he s udy. This no ewo hy inding emphasizes he signi icance o including all pa icipan s in he s udy, ensu ing ha e e yone can eap he bene i s o he in e en ion. The obse ed inc ease in co isol le els wi hin he con ol g oup unde sco es he po en ial impac o he in e en ion in mi iga ing s ess and i s ela ed physiological esponses. In assessing he e ec i eness o he ea men by he ela i e educ ion a e in he isk o wo sening symp oms, we highligh he pe cen age o pa icipan s in he con ol g oup who had inc eased hai co isol (60.0%), compa ed wi h only one pa icipan (6.7%) in he in e en ion g oup. Conside ing ha he e ec i eness o he ea men o pe cei ed s ess and anxie y was lowe han ha ound o capilla y co isol, despi e being ele an and posi i e, i is obse ed ha he physiological esul p ecedes he psychome ic one. Since he BAI and PSS o e acu e measu es o psychological dis ess while hai co isol measu es mo e ch onic s ess, hese migh ac ually be e e sed. This could be explained by he li e a u e sugges ing ha mind ulness can ac ually inc ease one’s awa eness o subjec i e anxie y and s ess mo e acu ely, since hey a e no longe a oiding i ; his makes one be e able o cope wi h i long- e m bu migh mask some o he indings o sel - epo ed da a o hese cons uc s [ 38 ]. I is alid o also conside he subjec i i y inhe en o he psychome ic assessmen using sel - epo scales [ 39 ] and, on he o he hand, he unconscious main enance o a condi ion ha gua an ees he pa icipan ’s eligibili y o p o essional assis ance on an in apsychic le el o hese wo ke s. We o e e idence based on alida ed psychome ic ins umen s and a eliable bioma ke o ch onic s ess— he mos widely used alida ion es , hai co isol [ 12 ]— ega ding he bene i s o he mind ulness p og am, which con ibu es o he p omo ion o men al heal h and he p e en ion o illness among uni e si y wo ke s. The implemen a ion o mind ulness p ac ices in he ou ine o hese wo ke s could cons i u e an impo an s a egy o managing s ess and i s long- e m consequences o he men al heal h and well-being o wo ke s in he uni e si y con ex . 5. Conclusions The mind ulness-based in e en ion o uni e si y wo ke s sample showed imp o e- men in a long- e m s ess bioma ke , accessed by hai co isol concen a ion, as well as in pe cei ed s ess and anxie y symp oms, measu ed by sel - epo ed scales. The e ec i eness o he in e en ion compa ed o he con ol g oup was highligh ed and co obo a ed by he wo sening o he condi ion in wo ke s who did no ecei e suppo o s ess manage- men . Such esul s aise impo an ques ions abou s ess in uni e si y wo ke s and i s ela ionship wi h he condi ions o he academic en i onmen . Heal hca e 2023,11, 2875 9 o 11 The eigh -week mind ulness-based in e en ion p og am was ele an o he p o- mo ion o men al heal h and could con ibu e o he p e en ion o diseases in uni e si y wo ke s. Fu he s udies a e needed o e alua e he e ec i eness o he in e en ion p og am, including o he men al heal h pa ame e s. Some limi a ions o conside a e ha he con ol g oup pa icipan s knew hey we e included in he wai lis condi ion, and ele an da a ela ed o ace and e hnici y we e no collec ed. The small sample size limi ed he gene alizabili y o he esul s. We conside ed ha he sample size was limi ed by an in e en ion ha las ed eigh weeks, since ha equi ed a commi men no e e yone was willing o make. Ano he possible limi a ion o he s udy is he d opou a e o 28.6%. Al hough adi ional andomized con olled ials accep a d opou a e o up o 20% [ 40 ], i has been no ed ha in mind ulness s udies, a a e o 16–29% is equen ly epo ed [41]. Au ho Con ibu ions: Concep ualiza ion, E.C.d.S.G.-D., L.B.H.G. and J.R.-G.; me hodology, E.C.d.S.G.- D., M.N.d.F.F., R.L. and E.B.C.J.; so wa e, R.L. and E.R.; alida ion, E.C.d.S.G.-D., K.V.D.-S., M.M. and J.R.-G.; o mal analysis, E.C.d.S.G.-D., K.V.D.-S. and E.R.; in es iga ion, E.C.d.S.G.-D., L.B.H.G., M.N.d.F.F., K.V.D.-S., M.M. and R.G.P.; esou ces, E.C.d.S.G.-D., M.N.d.F.F., E.B.C.J. and K.V.D.-S.; da a cu a ion, L.B.H.G., M.N.d.F.F., E.B.C.J. and E.R.; w i ing—o iginal d a p epa a ion, E.C.d.S.G.-D., L.B.H.G., M.N.d.F.F., E.B.C.J., K.V.D.-S., M.M. and E.R.; w i ing— e iew and edi ing, E.C.d.S.G.-D., M.N.d.F.F., K.V.D.-S., R.G.P. and E.R.; isualiza ion, E.C.d.S.G.-D., M.N.d.F.F., K.V.D.-S. and R.G.P.; supe i- sion, E.C.d.S.G.-D., L.B.H.G., M.N.d.F.F., K.V.D.-S. and J.R.-G.; p ojec adminis a ion, E.C.d.S.G.-D.; unding acquisi ion, E.C.d.S.G.-D. All au ho s ha e ead and ag eed o he published e sion o he manusc ip . Funding: This esea ch was unded by he Na ional Council o Scien i ic and Technological De elopmen —CNPq, announcemen MCTI/CNPq 01/2016, p ocess numbe . Ins i u ional Re iew Boa d S a emen : The s udy was conduc ed in acco dance wi h he Decla a ion o Helsinki and app o ed by he Ins i u ional Re iew Boa d o he School o Nu sing o he Uni e si y o Sao Paulo (p o ocol numbe 58376016.00000.5393, 21 Ap il 2020). In o med Consen S a emen : In o med consen was ob ained om all subjec s in ol ed in he s udy. Da a A ailabili y S a emen : The da a p esen ed in his s udy a e a ailable on eques om he co esponding au ho . The da a a e no publicly a ailable due o local e hical legisla ion. Con lic s o In e es : The au ho s decla e no con lic o in e es . Re e ences 1. Adekola, B. Wo k Bu nou Expe ience among Uni e si y Non Teaching S a : A Gende App oach. In . J. Acad. Res. Bus. Soc. Sci. 2012,2, 2222–6990. 2. Ali, S.; Fa ooqi, Y. 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