The Impact of Mobile Mindfulness Meditation on Mental Health and Well-Being in University Students
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The impact of mobile mindfulness meditation on mental health and well-being in university students A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy (Psychology and Psychological Medicine) by Jayde Ana Michelle Flett University of Otago 2019 ii Abstract of a thesis submitted in fulfilment of the requirements for the Degree of Doctor of Philosophy (Psychology and Psychological Medicine) The impact of mobile mindfulness meditation on mental health and well-being in university students by Jayde Ana Michelle Flett Mindfulness meditation is a common psychotherapy informed by Buddhist mindfulness that is gaining traction outside of the clinic. One area that is particularly popular is mobile mindfulness meditation, the use of applications (apps) to deliver mindfulness. Given the relative newness of these apps and the high turnover rate of app technology, few studies have rigorously examined the effectiveness of mindfulness meditation apps for improving mental health. Thus, in a series of pragmatic, randomised, controlled trials, I investigated the effects of mindfulness meditation apps on university students’ mental health. In this thesis I report the effects of Study 1, a randomised, controlled trial examining the effect of app-based mindfulness meditation on mental health and adjustment to college life in a convenience sample of undergraduate psychology students (Study 1). Here, I found that app-based mindfulness was associated with small but significant improvements in a range of mental health and well-being outcomes. I also found that there were app-specific effects which suggest that not all mindfulness apps are created equally. Study 1 provided the justification for Studies 2 and 3, where I investigated the effects of app-based mindfulness meditation on mental health in two targeted populations: a sample of clinically distressed university students who were seeking help through the university’s Counselling Service (Study 2), and a sample of incoming first-year university students living in one of two residential colleges (Study 3). In these studies, I identified barriers to implementation in complex contexts (Study 2) and that the transition to university (during the first semester of the first year of university) is an optimal time to intervene with incoming university students (Study 3). I took a pragmatic approach to effectiveness trials in all of the iii studies included in this thesis; that is, across all three trials I prioritised establishing the degree of effectiveness of mobile mindfulness meditation apps when they were used by a diverse population in a naturalistic setting, and where adherence is gently encouraged but not enforced. In doing so, I have contributed to the growing evidence of effectiveness for mobile MBI in real-world settings. Although we may think that the only way to use technology mindfully is to turn it all off, in this thesis I demonstrate that mobile mindfulness meditation can help improve university students’ mental health. Importantly, mobile mindfulness meditation was most effective among those who continued to use the app frequently. Identifying the factors that encourage sustained usage should be a priority for future research so that mindfulness app users can reap the rewards. iv Keywords: mindfulness, mobile health, young-adults, well-being, focus groups, semi-structured interviews, ecological momentary interventions, mHealth, randomised controlled trial, mental health List of abbreviations: ACT = Acceptance and Commitment Therapy ANZCTR = Australia and New Zealand Clinical Trial Registry BDI = Beck Depression Inventory CES-D = Centre for Epidemiological Studies Depression Scale DBT = Dialectical Behavioural Therapy FS = Flourishing Scale HADS = Hospital Anxiety and Depression Scale HADS-A = Hospital Anxiety and Depression Scale – Anxiety Subscale HADS-D = Hospital Anxiety and Depression Scale – Depression Subscale K6 or K10 = Kessler Psychological Distress Scales MBI = Mindfulness-based intervention MBCT = Mindfulness-based cognitive therapy MBSR = Mindfulness-based stress reduction NA = negative affect NIH = National Institute of Health (USA) NHS = National Health Service (UK) OR = odds ratio PA = positive affect PHQ-9 = Patient Health Questionnaire 9 pRCT = pragmatic randomised controlled trial PSS = Perceived Stress Scale RCT = randomised controlled trial RwCT = randomised waitlist-controlled trial SD = standard deviation SE = standard error SHS = Student Health Services SMC = Standardized mean change SMD = Standardized mean difference v vi Acknowledgements This thesis has been and will likely only be read by a select few: my supervisory dream-team, my extremely generous mother-in-law, and the (fingers-crossed) judicious examiners. Thank you for taking the time out of your busy lives to read the culmination of several years of work. I hope you enjoy it. Good luck and remember to breathe, ha! This body of research makes up a story of works that follow a similar theme. They are not the only work that has taken place over the last five years, merely the ones that fit into this story. A great deal of effort towards these projects, and others, has been contributed by a number of people whose names don’t make it onto the cover of this behemoth. For those that have helped me along the way, whether in terms of research support or as participants involved in this research, I give you my sincerest thanks. A global thanks isn’t really isn’t enough, so a brief acknowledgement will be made at the end of each study chapter acknowledging those who put in a great deal of time and resources to see these projects through. But there are a select number of people that I would like to thank in greater detail. First, I would like to give special thanks to my supervisors Professor Harlene Hayne, Associate Professor Tamlin Conner, and Dr Tess Patterson – a group of strong, independent, clever women who have formed a protective layer around me, pushing me to become a better academic and person over the last few years. It is not in jest that I call you the dream-team. I couldn’t fathom what a wealth of knowledge, support, and faith you would all be; I am very fortunate to have had the opportunity to grow under your tutelage. Second, I would like to thank the University of Otago for giving me the opportunity to carry out this PhD research and for providing financial assistance along the way. Additionally, to the Alumni of Otago in America, who supported my travel and further education in the United States of America. I would like to thank Dr. Kim Ma’ia’i for his support and advice as my Advisor. I would also like to thank Dr. Gareth Treharne and Dr. Damian Scarf for their vii important collaboration and advice, as well as Hadyn Youens for his technological input and Laura Thompson for her hard work and dedication as my research assistant and friend. Third, to my lab members, but especially to Ben Riordan and Roisin Hegarty. Ben, you have been my greatest collaborator, a best friend, and a great driving point. Without the ability to bounce ideas off you, I would probably still be writing this damn thing. I expect we have many years ahead of us to continue collaborating on projects. Roisin, without our lunchdates, your positive and pragmatic attitude, and your qualitative research experience, I would have never completed this thesis. And fourth, to my family and friends. To my parents and siblings, thank you for always believing in me and for always letting me take my own path. To my grandparents, for helping me keep my eye on the prize. To Imogen, for her keen eye, unwavering enthusiasm, and for Shannon. To my friends who have put up with my semi-regular existential crises. And finally to Tod. Thanks for joining me on this ‘wild ride’. You have been by my side since the very start. I am so glad that you didn’t let me scare you away at the get go. I hope we can have many more adventures together. viii PUBLICATIONS AND PRESENTATIONS Publications featuring in this thesis Flett, J. A. M., Hayne, H., Riordan, B. C., Thompson, Chapter 3 Lead author, co- L. M., & Conner, T. S. (2019). Mobile mindfulness designed study, ran the meditation: a randomised controlled trial of the effect study, led data of two popular apps on mental health. Mindfulness, collection, analysed the 10(5), 863-876. doi: 10.1007/s12671-018-1050-9 data; wrote publication. Flett, J. A. M., Fletcher, B. D., Riordan, B. C., Chapter 3: Lead author, co- Patterson, T., Hayne, H., & Conner, T. S. (2019). The Supplement designed study, analysed peril of self-reported adherence in digital 5 the data; wrote interventions: a brief example. Internet Interventions. publication. Online First. Flett, J. A. M., Conner, T. S., Riordan, B. C., Chapter 4 Lead author, co- Patterson, T., & Hayne, H (2020). App-based designed study, ran the mindfulness meditation for psychological distress and study, led data adjustment to college in incoming university students: collection, analysed the A pragmatic, randomised, waitlist-controlled trial. data; wrote publication. Psychology & Health, 1-26. Conference proceedings resulting from this thesis Flett, J. A. M., Hayne, H., Riordan, B. C., & Conner, T. S. (2015, September). But is there an app for that? The potential for mHealth uptake in student populations. Poster presented at the New Zealand Public Health Association Conference, Dunedin, New Zealand. Flett, J. A. M., Hayne, H., Riordan, B. C., Thompson, L., & Conner, T. S. (2016, September). Mobile mindfulness meditation: Benefits and barriers to uptake. Oral presentation at the New Zealand Psychological Society Conference, Wellington, New Zealand. Flett, J. A. M., Hayne, H., Riordan, B. C., Thompson, L. M., & Conner, T. S. (2016, November). Mobile mindfulness meditation: Using apps to cultivate well-being. Oral presentation at Kiwi Cognition and Memory, Dunedin, New Zealand. Flett, J. A. M., Hayne, H., Riordan, B. C., Thompson, L. M.