Working Women: Their perceived stress levels and nonpharmacological yoga intervention for management

Working Women: Their perceived stress levels and nonpharmacological yoga intervention for management | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Working Women: Their perceived stress levels and nonpharmacological yoga intervention for management Nidhi Khindri, Jyotsna Yadav This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5737717/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Work-related stress significantly impacts women’s mental health, leading to associated health issues requiring pharmacological interventions. With 37% of working women globally affected by stress, effective and accessible interventions are urgently needed. Objective: To evaluate the efficacy of Bhramari Pranayama (BP) in managing stress among working women using the Perceived Stress Scale-10 (PSS-10) and a validated self-help tool: Bhramari Pranayama Standard Operating Procedure (BPSOP). Methods: A single-arm clinical trial was conducted on 67 women aged 22–40 years with moderate to severe stress (PSS scores: 14–40). Exclusion criteria included low-stress scores (<13), severe psychological or systemic disorders, cardiovascular diseases, and ear infections. Participants underwent a 3-day in-person BP training followed by 20 days of intervention via the online Zoom platform. BP was practiced for 30 minutes daily (15 rounds) in the evenings. Pre- and post-intervention PSS-10 scores were compared. Results: The mean pre-intervention PSS score was 22.51, while the post-intervention mean was 14.28, showing a significant reduction. The calculated p-value (.000) was statistically significant, and the effect size (1.7) indicated a large magnitude of improvement, with post-intervention scores at the 95.5 percentile of pre-intervention values. Conclusion: Bhramari Pranayama is effective in reducing stress among working women. This effort is in line with Sustainable Development Goal (SDG) number 3 and highlights the need for action towards the fulfillment of SDG 5,8,10. Limitations include the single-arm design, small sample size, and online delivery. Future studies can explore its impact on hormonal stress markers and expand the findings through randomized controlled trials. The validated BPSOP tool offers a promising, accessible self-help intervention for stress management. The clinical trial was registered with the Clinical Trial Registry of India (CTRI) on 17 th April 2023 with the registration number CTRI/2023/04/051650. Preventive Medicine Women's studies Working women Stress Mental health Yoga Bhramari Pranayama SDG Figures Figure 1 Figure 2 Introduction As stress creeps into our lives stealthily and forms a bed for all the health issues, especially mental health issues, it must be dealt with in the very initial stage. Stress is dealt with, differently by different people due to genetic makeup, early experiences, socioeconomic conditions and personality traits. Left unattended for a long period, it causes physical and mental health problems. In the span of 15-20 years, work-related stress and its harmful repercussions have increased exponentially. Work stress can be defined as the untoward reaction towards the incapability to match up one’s skills with job requirements. (Singh,2023) Astonishingly, in the ranking of the most vulnerable population of employees, first are the child workers and second are women. Stress leads to different reactions, associated diseases and behavioral issues among workers, especially women workers. (Ornek,2020) Due to changed working scenarios and economic conditions, more difficulties have popped up in previous years for women employees who cope to maintain the work-life balance. Therefore, it is pertinent to work towards the prevention of job stress in our women force. Global prevalence of stress is 36.5% (Nochaiwong,2021). According to a report called “GOQii India Fit Report 22-23” of a ‘Stress & Mental Health Study’ conducted among 10,000 plus Indians, it was found that 24% of Indians are struggling with stress. Prominent stressors found to be were ‘workplace environment’ and ‘financial instability.’ Prevalence of Stress due to workplace among them came out to be 26% contributing factors being low salaries, long working hours, increasing competition and job insecurity; and 17% due to financial instability[1] Another source reported that in 2022, the prevalence of stress among employees in India was 38%[2]. Regarding the prevalence of working women in India, according to a report by Ministry of Labor and Employment 32.8% of females aged 15 years & above in India are participating in the labor force.[3]And the prevalence of working women in the state of Maharashtra came out to be 37.7%, with Pune city topping the charts .[4] A survey conducted by Delloitte covering 10 countries and 5,000 women showed that as compared to their global counterparts, Indian women are more stressed[5]. According to a study to assess the prevalence of anxiety and stress in Indian women, it was found that 26% were most prone and 66% were somewhat prone to stress.(Patel,2016) Indian ancient scriptures highlight the use of Yoga in our daily life to maintain the health of mind and body through the practice of various Asanas (physical postures), pranayamas (breathing techniques) and other components. Pranayama is a special practice that has been found to work on mental health. According to yogic texts, pranayama is given more importance than asana to attain good health. Different types of pranayama are known for their benefits. Among those various types, Bhramari Pranayam (BP) is one such pranayama which relieves stress and cerebral tension, increasing the healing capacity of the body. While performing it, the practitioner inhales and exhales through the nostrils slowly and deeply. While exhaling, a humming sound is produced like a bumble bee, through the nostrils, keeping eyes, oral cavity and ears closed by fingers in a special pose called Shanmukhi mudra . It strengthens and improves the voice. It induces a meditative state by harmonizing the mind and directing the awareness inward. The vibration of the humming sound creates a soothing effect on the mind and nervous system. Probable modes of action of BP on stress reduction may be due to the ‘humming sound’ that leads to powerful visualization inwards, vibrating the head and brain due to acoustic vibrations. As a result, the cerebral cortex on getting vibrated stimulates the hypothalamus and parasympathetic nervous system. The hypothalamus controls the pituitary gland and the parasympathetic nervous system is responsible for peace and composure of mind and body. This leads to harmonious synchronization of the neuroendocrinal system. While studying the literature pertaining to study topic it was found that more interventional experimental studies are required to prove with evidence, the effect of BP on stress levels. Many studies have been conducted to see its integrated effect with other yogic techniques or its add-on effect with other pharmacological interventions on various health conditions. As per our knowledge, no single study has been conducted to check the individual effect of BP solely on stress. Also, no study has been done yet to apply the above results to the population of working women. Ranking of women second to child workers in being the most vulnerable population of employees towards stress; and global prevalence of working women being 37%, draws immediate attention. ‘Work-related stress’ takes a high toll on women’s mental health and by the time they realize that stress has overtaken them, they fall into the trap of associated health problems and their symptoms which need pharmacological interventions. And once caught into medications, it’s difficult to come out of its vicious circle of dependency, habit forming and side effects. Moreover, such medications cause hormonal imbalance, further deteriorating the condition in women leading to menstrual and reproductive problems. Furthermore, for women especially, taking medications for stress comes with a social taboo. It is pertinent to work towards the prevention of job stress in our women force with the help of non-pharmacological intervention. The need of the hour is to empower these women with a tool to tackle stress privately. This is an effort towards the fulfillment of Goal 3 (good health and well-being), Goal 5 (Gender Equality), Goal 8 (Decent work and economic growth), and Goal 10 (Reduced Inequalities) enlisted in the World Health Organization’s (WHO) Sustainable Development Goals (SDG). So, lifestyle modification incorporating BP as a non-pharmacological Yoga Intervention can provide an effective solution to the said problem. Therefore, this research was conducted. This study aimed to evaluate the efficacy of Bhramari Pranayam in the management of stress in working women through an instrument called the Perceived Stress Scale-10 (PSS-10) questionnaire. It was hypothesized that there is a significant difference in the mean value of the PSS-10 score before and after the intervention of Bhramari Pranayam. A self-help tool called Bhramari Pranayama Standard Operating Procedure (BPSOP) was developed, specially customized for working women. The development, validation, and pilot testing of this tool will be detailed in the subsequent publication. [1] https://www.deccanherald.com/business/24-of-indians-are-struggling-with-stress-report-1197723.html [2] https://www.statista.com/statistics/1339190/india-share-of-burnout-and-distress-rate-among-employees/ [3] https://dge.gov.in/dge/sites/default/files/2023-05/Female_Labour_Utilization_in_India_April_2023_final__1_-pages-1-2-merged__1_.pdf [4] https://pib.gov.in/Pressreleaseshare.aspx?PRID=1805783 Source: Periodic Labour Force Survey (PLFS), July 2019- June 2020, M/o Statistics & Programme Implementation. [5] https://www.linkedin.com/pulse/indian-women-more-stressed-than-global-counterparts-varinder-singh/ Methods This study was approved by the institutional ethics committee (approval number: DYPCARC/IEC/ 5 6 4/2022). The clinical trial was registered with the Clinical Trial Registry of India (CTRI) on 17 th April 2023 with the registration number CTRI/2023/04/051650. This qualitative research followed the design of a Pre-test and Post-test model in a Single-arm clinical study. The recruitment of participants was done at the institution's outpatient department (OPD) Consultants of the outpatient department were informed about the study who then presented it to the potential participants under their care. Three research tools were used, namely, the PSS-10 questionnaire, the developed BPSOP, and a training sheet. One piece of equipment was used namely the yoga mat. The perceived stress scale, developed by Cohen et al. (1983), is a self-reported instrument to measure the degree to which situations in one’s life are perceived as stressful. With reliability and Cronbach’s alpha value as 0.91,it is a validated scale. Earlier it consisted of 14 items and later it was reduced to 10 item scale in 1988.Each item is scored on a 5-point scale (0 = “never,” 1 = “rarely,” 2 = “sometimes,” 3 = “often,” and 4 = “very often”), with items 4, 5,7,8, being reverse-scored items (scores 0,1,3 are reversed to 4,3,1, respectively and vice versa. The score of 2 remains unchanged). The scores of all items are added together to obtain a total score, which ranges from 0 to 40 points: the higher the score, the greater the psychological stress. scores of 0 – 13 are considered low stress, 14 – 26 moderate stress, and 27 – 40 are high perceived stress. PSS-10 used is mentioned in table 1. BPSOP is the standard operating procedure developed for the practice of Bhramari pranayama , tailored according to the needs of each working woman participant. It was tested, validated, and used as an intervention for the study group in the clinical trial. BPSOP is described in table 2. During the pilot testing, it was observed that not all participants were picking up BPSOP at once. So, to prevent bias, it was decided to provide training to each participant for three days before the start of the trial. Therefore, to record the pace of acceptability of the BPSOP for each participant a training sheet consisting of different aspects of BPSOP was prepared and divided into seven items to be ticked by the researcher as and when the participant performed well. (Table 3) Purposive Sampling was employed to recruit the participants. Recruitment was done at ‘Swasthavritta and Yoga’ O.P.D of Dr.D.Y.Patil College of Ayurved and Research Centre, Pune, India. Consultants of the OPD were informed about the study who then presented it to the potential participants under their care. Those participants were explained about the study details and their written informed consent was sought. A pre-test was conducted using PSS-10 and scores for each participant were calculated to screen them. The selection was done according to the criteria mentioned ahead. Inclusion criteria comprised of women aged between 22 to 40 years, working for minimum 8 hours in continuation per day at a workplace, and with a score of 14-40 on PSS which form the moderate and severe stress categories. Exclusion criteria comprised of women participants with a score of less than 13 on PSS, which forms the low-stress category, known cases of severe psychological and systemic disorders, and those contra-indicated for BP, such as known cases of severe cardiovascular diseases and ear infections. Withdrawal Criteria comprised of participants who practiced non-adherence for even a single day and reported any adverse events. The sample size was calculated as 67 and the duration of study was 18 months in total including 20 days of Clinical trial. A clinical case sheet proforma about the study was prepared and used to record the selected participants' information and observations. All selected participants were allocated to the intervention of BP, for which a 3-day training was given to all in person at the institution’s yoga hall to practice different aspects of BPSOP, and their progress was recorded every day in the training sheet developed for the same. The training was followed by the session of non-pharmacological Yoga intervention of BP in 15 rounds in continuation for 20 consecutive days in the evening (30 minutes) through the online Zoom platform as per the developed, validated, and tested BPSOP. Phone calls and text messages were used as reminders for the session every day. Per-day session notes were written in a diary, mentioning the number of attendees, unintended observations, inputs, and suggestions from the participants. A post-test was conducted on the last day using the same PSS-10 and scores for each participant were calculated. Scores of the Pre-test and post-test were compared. Descriptive statistics was used to summarize and describe the data. Inferential statistics was applied to test the hypothesis using the Wilcoxon Signed rank test as the data, although normally distributed, was ordinal and discrete, and the study is based on the Pretest-Posttest model. The IBM SPSS version 21 software was used for this.The statistical significance of the result was checked through the ‘P-value’ calculation. The clinical significance of the result was checked through the ‘Effect size’ (ES) calculation. Effect sizes represent the mean change observed in a variable divided by the standard deviation of that variable. They serve to standardize "before and after changes" in a single-group context, offering a clearer and more consistent interpretation of health status outcomes. "Effect size as used in this study is calculated by taking the difference between the means before treatment and after treatment and dividing it by the standard deviation of the same measure before treatment. This method of calculating effect sizes can be expressed mathematically as ES = (mi - m2)/sl, where m, is the pretreatment mean, m2 the posttreatment mean, and s, the pretreatment standard deviation. In this instance the before-treatment scores are used as a proxy for control group scores. This approach treats the effect size as a standard measure of change in a "before and after study" context. We are interested in the magnitude or size of the change rather than statistical significance, so we use the standard deviation at baseline rather than the standard deviation of the difference between the means. Effect sizes can be used to translate changes in health status into a standard unit of measurement that will provide a clearer interpretation of the result” (Kazis,1989). Interpretation of effect size was done according to Cohn’s Standard classification (Sullivan,2012) (Table 4) Results A total of 100 people were screened for eligibility. Out of these, 69 were selected as per the inclusion criteria. The remaining 31 were excluded as they had a score of less than 13 on PSS-10. All 69 were allocated to the intervention who started BP sessions. 2 participants were withdrawn due to non-adherence after 5 days from the start of the intervention session. Analysis was done for the remaining 67 participants. The consort chart is given in Figure 1. The participants’ demographics and other characteristics are shown in Table 5. The total scores on PSS-10 for all 67 participants were compared through a Pre-test (Before BP intervention) and a post-test (after BP intervention), shown in Figure 2. Participants were numbered according to different stress categories before and after the BP Intervention. It was concluded that the before and after numbers for the low-stress category were 0 and 28, respectively. Before and after numbers for the moderate stress category were 52 and 39, respectively. The before and after numbers for high stress category were 15 and 0, respectively. (Table 6) Analysis of responses to each question of PSS-10 was done and summarized in Table 7. As, each type of response in PSS-10 has got a score value like 0 for ‘Never’, 1 for ‘Almost never’, 2 for ‘Sometimes’, 3 for ‘Fairly often’, and 4 for “Very often’, scores for ‘before & after’ responses of all 67 participants to each question were totaled and the values of mean, standard deviation were calculated. Thereafter, using the Wilcoxon Signed Rank test, Z and P-values were calculated. Finally, the percentage effect was computed. The same was done for total scores too. The summary of statistics is given in Table 8. The mean score values decreased remarkably after the intervention for each question and the total score, and all the p-values came out to be less than 0.05. Also, the intervention had a notable percentage of effect on the response score for each question. Therefore, it was deduced that the results are statistically significant and there is strong evidence to reject the null hypothesis, i.e. “There is no significant difference in the mean value of PSS score before and after the intervention of Bhramari Pranayam .” The effect size of 1.7 was calculated by taking the difference between the means before treatment and after treatment and dividing it by the standard deviation of ‘before treatment’ using the formula ES = (m1 - m2)/s where m1 is the pretreatment mean, m2 the posttreatment mean, and s is the pretreatment standard deviation. Therefore, ES= 22.5075-14.28366/4.806481, which gives the value of 1.7. According to Cohn’s Standard classification, an effect size of 1.7 indicates that the mean of the post-treatment is at the 95.5 percentile of the Pre-treatment. Hence, it was concluded that the effect of the intervention had a large magnitude, which implies that the results are clinically significant. The result analysis is summarized in Table 9. Discussion In this study, we evaluated the efficacy of BP in managing the perceived stress levels of working women and it was inferred that BP through BPSOP is effective in reducing stress. Stress forms the bed for all kinds of health issues, so it’s important to nip it in the bud as it gradually progresses into severe medical conditions if left untreated. The reason behind choosing women as the target population in this study was that women are twice as likely as men to develop symptoms of stress.[6] Hammen et al. (2009) reported that women are more prone to mental health problems that worsen due to stress, anxiety and depression. Among women, those who are working are more prone to stress (Joseph,2019). Second, only to child workers, women are the most vulnerable population of employees. Panigrahi (2017) says that Job stress is known as the “illness of the century.” Singh (2023) revealed that the majority women are dealing with higher levels of occupational stress. Another study by Gyllensten (2005) found that as compared to men, a higher level of stress is faced by working women; Common stressors came out to be work overload, juggling of multiple roles, stereotyping and discriminatory practices; ‘Role overload’ is a significant stressor for working women as they have to play different roles at the workplace and with family and most of them are unable to do equal justice at both the places which leads to fatigue, disappointment, and stress. A prolonged stressful phase leads to the development of symptoms like headache, hypertension, obesity and even stroke. Stress is also termed the silent serpent for working women (Lakhute et al. 2024). While exploring intervention methods to manage stress, it was found that non-pharmacological interventions (NPI) being cost-effective can be the potential solution for better living, preventing disease, and self-care. Among the NPI, Yoga was chosen due to factors like its ‘ease of doing’ irrespective of time and place, maintaining privacy, and less time-consuming, considering the hectic schedules of working women and time paucity to make self-care efforts. In Yoga too, Pranayayam was chosen due to its simple technique, short duration, and amplified results for the improvement of mental health. From among various Pranayams , Bhramari was the choicest kind due to its scientifically proven effect on stress and other compromised mental health conditions. The current scenario of our busy schedules does not allow us to focus on our physical health leave apart mental health. So, the BP Procedure was designed meticulously and customized thoughtfully in the form of BPSOP to cater to busy working women. It was kept easy to grasp, short, crisp, easy to self-perform, and to apply in routine throughout life. Dividing the rounds into sets with breaks in between made it comprehensible and acceptable to the women participants. Stress scores when evaluated according to age, it was found that 31.3% belonged to the age group 26-30 years, followed by 25.4% ,17.9% that belonged to age groups 21-25years, and 31-35 years respectively. And for the age group of 36-40 years, another 25.4% was recorded. This shows that the age between 26-30 years is the most stressful phase for working women, probable reasons being marriage aspect, career prospects, family planning, etc. as these years are the formative years of the above factors. A study by Jeganathan K (2019) conducted to check relation between age and occupational stress revealed that age plays a pivotal contributor towards stress in women who are working, showing women of age 45 years and above, (which was excluded in our study for the possibility of being known cases of various diseases) face more stress as compared to other age groups followed by women of the group 25-34 years, which coincides with our result. Another study to evaluate stress in working women showed women in age group 18-25 years deal with stress the most, which is different from that of ours. Among the occupations included in the study, Physicians stand out as the largest number of participants contributing to almost 20% for the relation of occupation and stress in working women. Research done on Perceived stress of women health care workers showed a high prevalence of stress in the mentioned sector, which strengthens our finding (Prashar M.et al.2017). Among the women studied here, 45 were married and 22 were unmarried showing the high incidence of perceived stress in women who are married and working. Different but not far were the results of the study of Prashar M.et al.(2017) in which out of 64 respondents,31 were married and 33 were unmarried who were working and dealing with stress. Another research by Panigrahi (2014) also revealed similar results that married women are experiencing more stress than unmarried women due to traditional trends, demands of society and more roles and responsibilities assigned to them as a mother, wife and homemaker. PSS-10 judges an individual on three parameters i.e. total scores, helplessness and lack of self-efficacy. Higher scores represent higher levels of stress. In PSS there are two subscales of helplessness and lack of self-efficacy. Question numbers 1,2,3,6,9,10 measure individual’s lack of control over circumstances or their reactions. Question numbers 4,5,7,8 measure an individual’s inability to handle problems. As PSS deals with an individual’s perception of stress and its subscales measure one’s perception of helplessness and lack of self-efficacy, accordingly interpretation of mean scores, p-values and their percentage effect per question of PSS have been discussed ahead along with the probable mode of action of BP on each one of it. To begin with, first question deals with one’s lack of control over some unexpected happening. The mean score of its responses before and after intervention was 2.4478 and 1.2687, respectively. A significant reduction in the mean scores, before and after Bhramari practice, to nearly half reflects improved control over circumstances. Also depicted that participants were 48% more capable of dealing with unexpected or untoward circumstances positively. Probable reasons for such a result could be that Bhramari practice increases the production of nitric oxide (NO) in the body (Kumar,2021). And NO is known to inhibit the production of Cortisol - the stress hormone. Particularly, the humming sound produced during the exhalation phase of BP ramps up the generation of NO by 15-fold as compared to quiet exhalation. Thus improving one’s reaction towards unexpected happenings (Rajesh 2014). Also, Bhramari practice shortens reaction time which means improvement in information processing and reflexes, resulting in improved cognitive function (Kuppusamy et al. 2021). The second question checks one’s control over important things in one's life. The mean scores of its responses before and after intervention were 2.6716 and 1.4925, respectively. Here too, a comparison of before and after mean scores shows a reduction to approximately half and their difference shows that participants were 44% more capable of asserting control over their life’s important things. Probable reasons can be that Acoustic Vibration produced by the humming sound stimulates brain tissues (Chetry et al.2024). Also, BP activates the parasympathetic nervous system leading to a calmer state of mind which helps in prioritizing important things of life (Ismail et al.2022). The third question deals with one’s frequency of feeling nervous and stressed. The mean scores of its responses before and after intervention were 2.6716 and 1.5522, respectively. Again, mean scores show a reduction to nearly half, post-intervention showing that the frequency of feeling nervous and stressed by the participants reduced by 42%, which is a remarkable finding. As Bhramari Pranayam increases the activity of the parasympathetic nervous system, decreasing that of the sympathetic nervous system, which in turn decreases cardiovascular parameters like blood pressure and heart rate which lead to a reduced nervous and stressed state of mind (Kuppusamy et al.2016). Also, Bhramari leads to bliss kind of feeling in an individual (Kuppusamy et al.2017). According to a study, Bhramari is a relaxation technique that works on neuromodulating principles to reduce stress and anxiety, supporting our findings (Pandey et al.2010). So, a person’s perceived ability to handle problems is boosted. The fourth question asks the subjects about the frequency of their feeling confident for their ability to handle personal problems. The mean scores of its responses before and after intervention were 1.3433 and 1.1194, respectively. Difference in the mean scores show that their confidence in themselves increased by 17%. According to a few clinical control trials, practicing Bhramari even for a short duration improves attention performance significantly (Kala et al.2023, Sharma et al. 2022, Pradhan et al.2018). Another single-group clinical study concluded that practicing BP for a short term resulted in a considerable rise in alpha-EEG (Trivedi et al.2023). And alpha waves are associated with bringing about a state of deep relaxation. These results may be the probable reasons behind our finding on this particular question. The fifth question deals with the perception of subjects regarding taking things as favorable to their way. The mean scores of its responses before and after intervention were 1.9254 and 1.4478, respectively. Differences in the mean scores reflect that intervention had a positive effect on the perceived ability to deal with problems. The percentage effect came out to be 24.81%. This finding gets weightage by the result of a study that says the humming sound created during exhalation generates the lowest stress index when compared to other activities like physical activity, emotional stress and sleep. It can be a strong stress buster. A regular daily humming routine can enhance parasympathetic activity leading to the normalcy of stress hormones which helps in positively tackling things (Trivedi et al., 2023). Another study concluded that the practice of BP improves the feeling of physical and mental well-being (Beldar S et al. 2020) .These findings coincide with and support our results. The sixth question examines the subjects for their helplessness frequency to cope with their tasks. The mean scores of its responses before and after intervention were 2.4925 and 1.5821, respectively. Mean scores showed a reduction post-intervention and around 37% decrease was seen on average, in the perceived lack of control over circumstances. A study conducted to find the effect of BP on physical and physiological parameters among cricketers concluded that its practice improves cardio-respiratory endurance; increases speed, flexibility, vital capacity, and haemoglobin percentage; and reduces pulse rate, blood pressure and respiration rate of resting state (Pratap et al.2017). It provides evidence and support for our findings. Due to all the above, we can conclude that subjects feel empowered to tackle their tasks. The seventh question speaks about the amount of self-efficacy of participants to control irritations in their lives. The mean scores of its responses before and after intervention were 1.7015 and 1.3433, respectively. A reasonable difference in pre and post-mean values of responses was noticed showing a 21% increase in the ability of the participants to deal with irritations. According to Kuppusamy et. al (2016) BP has an instant calming effect, relieving anger, stress, and anxiousness. Also, it concludes that Bhramari practice releases hormones linked with the state of joyfulness and peace like endorphin and encephatin. It decreases dopamine secretion which is known as the stress hormone. This mechanism may be the probable reason to support our finding. Moving on to the next eighth question, which asks about the frequency of feeling on top of things. The mean scores of its responses before and after intervention were 2.1194 and 1.4627, respectively. Mean value changes in its responses are decent showing around a 31% increase in the capability of the participants to feel that way. A study concluded that humming sound enhances the resonance of mind, forming vibrations in the brain that elevate positive mood in an individual (Srivastava et al. 2017). This breathing pattern enables a person to gain full control of one’s mind and emotions. This result coincides with our findings. A study on brain wave frequency and BP stated that due to bhramari practice gamma waves are found to be positively affected and that is significant as it reflects the increased activity of multiple areas of the brain simultaneously, which makes a person feel on top of the things (Prasad et al. 2006). The ninth question on PSS judges the perceived incapability of subjects to control their anger. The mean scores of its responses before and after intervention were 2.7910 and 1.6716, respectively. In this question, responses showed a marked change in pre and post-mean values, reflecting that their ability to deal with anger increased by 40%. This finding may be backed by the results of the study which says that bhramari practice alleviates aggression by producing vibrations in the mind through which the hypothalamus and pituitary glands are controlled to eliminate anger. Stimulation of the autonomous nervous system increases the secretion of the noradrenalin hormone which in turn reduces the secretion of hormones related to anger and anxiousness (Srivastava et al 2017). This is how Bhramari may be working in bringing about changes to the responses to the said questions. The tenth and last question deals with the incapability of subjects to deal with piled-up difficulties which form a roadblock for them. The mean scores of its responses before and after intervention were 2.3433 and 1.3433, respectively. There was a significant difference in the mean scores before and after intervention. The marked effect was seen in percentage effect too, showing around 43% positive change in the ability of the participants to deal with difficult tasks. A study conducted by Prasad et al.( 2006) to see changes in the pattern of EEG after practicing bhramari pranayam revealed that bhramari produces quick changes in all brain wave signals of delta, theta, alpha, beta and gamma frequencies. Results of above-mentioned study provides evidence to our finding. It concludes that a simultaneous positive effect on all brain wave patterns leads to remarkable and profound ability of an individual to perform complex task. Delta waves open the gateway of learning and increase intuition and creativity. Theta improves sleep; Alpha takes one into deep relaxing state; Beta increases alertness and visual sharpness and lastly gamma helps accomplish difficult and complex tasks involving multiple areas of brain. Overall effect of BP is reflected in the mean values of total scores of PSS. The mean values of total score before and after intervention were 22.5075 and 14.2836, respectively. Marked changes were seen in Pre and post-total scores. The mean value for post scores was reduced and a significant p-value of 0.000 was calculated, reflecting around 37% positive overall effect in stress reduction due to BP. Results of various studies conducted on brain wave patterns support our finding which revealed that Bhramari alters EEG data in the frontal & temporal regions of the brain, causes symmetric activation in the prefrontal region and strengthens synchronization of the temporal lobe (Jin et al.2014,Prasad and Matsuno.2007,Prasad et al.2007). A study by Sahu (2015) reported a considerable rise in alpha EEG after Bhramari practice for a short duration.Few other studies concluded that Bhramari practice improves attention performance(Kala et al.2023, Sharma et al.2022,Pradhan et al.2018). Studies conducted on stress reduction revealed marked changes in stress levels(Jagadeesan et al.2022,Kumar 2021, Maheshkumar 2022) . Various other studies proved improvement in sleep quality(Jagadeesan et al.2022,Kumar 2021, Bhati et al.2017); quality of life (Jagadeesan et al.2022,taneja 2018); and overall mental health(Srivastava et al.2017). Furthermore, many other studies conducted to prove the result of Bhramari on cardiovascular functions, pulmonary functions, neuro-endocrine functions reveal that the synergistic effect of all mentioned above breaks the patho-physiology of stress. One unintended observation was recorded as one participant complained of being shaky and drained on 3rd day after taking the intervention. For that reason, she was asked to check blood pressure readings from the 4th day onwards before and after the session. It was observed that Bhramari practice had a normalizing effect on Blood pressure readings for that participant, i.e., if Blood pressure was a little more than the normal range of Diastolic/systolic (120/80 mmHg ) before intervention, it got normalized after intervention and vice- versa. Previous studies like Single-group clinical trials, as well as clinical control trials with very short- to short-term follow-up periods, revealed increased heart rate, total peripheral resistance, diastolic blood pressure, and mean arterial pressure with a significant reduction in pulse interval, stroke volume, and cardiac output during BP. Following the practice, there were significant drops in heart rate, pulse rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, rate-pressure product and double product (Chetry et al.2024, Latha 2022). Limitations Some strengths and limitations were identified in our research. The single-arm design of the study limited the scope of comparison in the absence of control. The small sample size enabled an in-depth analysis but restricted the range of effectiveness. The online platform chosen to provide the intervention might have brought in the bias. After conducting the pilot study, it was identified as a compulsion in this case, considering the working nature and different work timing of the participants. [6] https://www.womenshealth.gov/mental-health/good-mental-health/stress-and-your-health Conclusion The present study aimed at evaluating the efficacy of Bhramari Pranayama on the stress levels of working women through the PSS scores showed that after 20 days of practice of bhramari pranayam, there was a significant reduction in the stress levels of working women. The mean of the post-treatment is at the 95.5 percentile of that of the Pre-treatment, showing the clinical significance of the intervention. The mean of the total score, pre-intervention, was 22.5075 and the mean of the total score, post-intervention, was 14.2836, showing a marked difference in the values. The calculated p-value came out to be .000, which is less than 0.05 and is statistically significant. Individually, too, for all ten questions of PSS, the p-value came out to be less than 0.05. Therefore, it can be inferred that Bhramari pranayam is effective in managing the stress levels of working women. The results of this study can be applied in the future to see the changes in hormonal profiles and stress markers (serum cortisol, alpha amylase). The same effect can be evaluated by targeting different populations to mitigate stress. Results from further randomized control trials are required to translate the findings of this study. Developed BPSOP can prove to be a ready tool for self-help and further research. This is an effort in line with goal 3 (good health and well-being), goal 5 (Gender Equality), goal 8 (Decent work and economic growth), and goal 10 (Reduced Inequalities) enlisted under the SDG of WHO. Statements and Declarations Funding:The authors did not receive support from any organization for the submitted work. Competing interests: The authors have no relevant financial or non-financial interests to disclose. Ethics approval:This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Institutional Ethics Committee of Dr.D.Y.Patil College of Ayurved and Research centre (Date- 05/08/2022/No.-DYPCARE/IEC/564/2022). Clinical Trial Registration: Date-17/04/2023; CTRI No.-CTRI/2023/04/051650 Consent to participate: Informed consent was obtained from all individual participants included in the study. Authors’ contribution statements: All authors contributed to the study’s conception and design. All authors read and approved the final manuscript. References Ashok panigrahi.Jan (2017).Managing Stress at Workplace.Journal of Management Research and Analysis, October-December,2016;3(4):154-160. Beldar S, Bhati K. (2020) Evolution of bhramari pranayam in the management of menopausal syndrome. Ayushdhara.;7:2791-7.DOI: https://doi.org/10.47070/ayushdhara.v7i4.594 Bhati KR, Bhalsing V, Manglekar A.(2017) Assessment of nidra as adharniya vega and its management with bhramari pranayam. World J Pharm Res.;7:1527-41.DOI: 10.20959/wjpr20183-10982 Chetry D, Chhetri A, Rajak DK, Rathore V. Gupta A.( 2024) Exploring the health benefits of bhramari pranayama (humming bee breathing): A comprehensive literature review. Indian J Physiol Pharmacol.;68:71-85. doi:10.25259/IJPP_325_2023 Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24(4), 385–396. Gyllensten K, Palmer S (2005). The role of gender in workplace stress: A critical literature review. Health Education Journal, 64(3), 2005, 271-288 DOI:10.1177/001789690506400307 Hammen, C., Kim, E.Y., Eberhart, N.K., Brennan, P.A. (2009). Chronic and acute stress and the predictors of major depression in women. Depression and Anxiety; 26(8): 718–723. Ismail AMA, Ali SM, Ghuiba K, Elfahl AMA, Tolba AMN, Ghaleb HAM. (2022 )Autonomic functions, tinnitus annoyance and loudness, and quality of life: Randomized-controlled responses to bee-humming (vibrational) respiratory training in tinnitus elderly. Complement Ther Clin Pract. Aug;48:101611. doi: 10.1016/j.ctcp.2022.101611. Epub 2022 Jun 3. PMID: 35675742. DOI: 10.1016/j.ctcp.2022.101611 J. Jin, J. Dauwels, F. B. Vialatte and A. Cichocki,( 2014) "Synchrony analysis of paroxysmal gamma waves in meditation EEG," 2014 IEEE International Conference on Acoustics, Speech and Signal Processing (ICASSP), Florence, Italy, pp. 4703-4707,.DOI: 10.1109/ICASSP.2014.6854494 Jagadeesan T, Archana R, Kannan R, Jain T, Allu AR, Selvi GT, et al. (2022) Effect of bhramari pranayama intervention on stress, anxiety, depression and sleep quality among COVID 19 patients in home isolation. J Ayurveda Integr Med.;13:100596. DOI: 10.1016/j.jaim.2022.100596 Jeganathan, Krithika. (2019). Organizational demography: Age as a determinant of occupational stress among the women working in Chennai. International Journal of Advanced Research. 4. 1-3. Joseph, JK & Devu BK (2019). A comparative study to assess the level of stress among working and non working women. nternational Journal of Recent Scientific Research Vol. 10, Issue, 04(G), pp. 32094-32097, April, 2019 DOI:10.24327/ijrsr.2019.1004.3397 Kala N, Telles S, Sharma SK, Balkrishna A. (2023) P300 following four voluntarily regulated yoga breathing practices and breath awareness. Clin EEG Neurosci;54:117-29. DOI: 10.1177/15500594221089369 Kazis LE, Anderson JJ, Meenan RF.(1989) Effect sizes for interpreting changes in health status. Med Care. Mar;27(3 Suppl):S178-89. doi: 10.1097/00005650-198903001-00015. PMID: 2646488. Kumar A, Venkatesh S.( 2021) Effect of short-term practice of bhramari pranayama on sleep quality and perceived stress in school students. Int J Physiol.;9:1-6. DOI: https://doi.org/10.37506/ijop.v9i1.2603 Kuppusamy M, Kamaldeen D, Pitani R, Amaldas J, Ramasamy P, Shanmugam P, Thirupathy V. (2021)Effect of Bhramari pranayama practice on simple reaction time in healthy adolescents – a randomized control trial. International Journal of Adolescent Medicine and Health.;33(6): 547-550. https://doi.org/10.1515/ijamh-2019-0244 Kuppusamy M, Kamaldeen D, Pitani R, Amaldas J, Shanmugam P. (2017)Effects of Bhramari Pranayama on health - A systematic review. J Tradit Complement Med. 2017 Mar 18;8(1):11-16. doi: 10.1016/j.jtcme..02.003. PMID: 29321984; PMCID: PMC5755957.doi: 10.1016/j.jtcme.2017.02.003 Kuppusamy M, Kamaldeen D, Pitani R, Amaldas J. (2016) Immediate Effects of Bhramari Pranayama on Resting Cardiovascular Parameters in Healthy Adolescents. J Clin Diagn Res. May;10(5):CC17-9. doi: 10.7860/JCDR/2016/19202.7894. Epub 2016 May 1. PMID: 27437210; PMCID: PMC4948385.doi: 10.7860/JCDR/2016/19202.7894 Lakhute, S. vitthalrao ., Band, R. M. . and Rajasekaran, P. K. (2024) “Stress Among Working Women: A Silent Serpent”, National Journal of Community Medicine, 15(06), pp. 509–510. doi: 10.55489/njcm.150620243895. Latha R, Lakshmi SS. (2022)A study on immediate and training effect of bhramari pranayama on heart rate variability in healthy adolescents. Biomedicine.;42:784-8.DOI: https://doi.org/10.51248/.v42i4.1501 Maheshkumar K, Dilara K, Ravishankar P, Julius A, Padmavathi R, Poonguzhali S, et al. (2022)Effect of six months pranayama training on stress-induced salivary cortisol response among adolescents-randomized controlled study. Explore (NY).;18:463-6 DOI: 10.1016/j.explore.2021.07.005 Nochaiwong S, Ruengorn C, Thavorn K, Hutton B, Awiphan R, Phosuya C, Ruanta Y, Wongpakaran N, Wongpakaran T. (2021).Global prevalence of mental health issues among the general population during the coronavirus disease-2019 pandemic: a systematic review and meta-analysis. Sci Rep. 2021 May 13;11(1):10173. PMID: 33986414; PMCID: PMC8119461.doi: 10.1038/s41598-021-89700-8 Pandey, N.K. Mahato, R. Navale (2010).Role of self-induced sound therapy: bhramari pranayama in tinnitus Audiol Med, 8 (3), pp. 137-141 DOI: 10.3109/1651386X.2010.489694 Panigrahi, A., Padhy, A. P., & Panigrahi, M. (2014). Mental health status among married working women residing in Bhubaneswar city, India: a psychosocial survey. BioMed research international, 2014, 979827. https://doi.org/10.1155/2014/979827 Patel PA, Patel PP, Khadilkar AV, Chiplonkar SA, Patel AD.(2017)Impact of occupation on stress and anxiety among Indian women. Women Health. Mar;57(3):392-401. doi: 10.1080/03630242.2016.1164273. Epub 2016 Mar 16. PMID:26984269. DOI: 10.1080/03630242.2016.1164273 Pradhan B, Mohanty S, Hankey A.(2018) Effect of yogic breathing on accommodate braille version of six-letter cancellation test in students with visual impairment. Int J Yoga.;11:111-5.DOI: 10.4103/ijoy.IJOY_40_17 Prasad R, Bakardjian H, Cichocki A, Matsuno F. (2007 )Source localization with EEG data for BP shows major activities in the frontal areas of the brain. InSICE Annual Conference 2007 Sep 17 (pp. 774-778). IEEE.DOI: 10.1109/SICE.2007.4421087 Prasad R, Matsuno F. (2007) Hummgenic changes in large scale temporal correlation of EEG in BP. InSICE Annual Conference 2007 Sep 17 (pp. 2068-2073). IEEE.DOI: 10.1109/SICE.2007.4421328 Pratap Bhushan, Kunwar Bipin & Nathani, Neeru & Tripathi, Narendra. (2017). Impact of Bhramari Pranayama on Cardio Respiratory Endurance among the Cricket Players with Special Reference to Prakriti (Psycho-somatic Constitution).International Journal of Physical Education and Sports.Volume: 2, Issue: 9, Pages: 08-13 Rajesh SK, Ilavarasu JV, Srinivasan TM. (2014) Effect of bhramari pranayama on response inhibition: Evidence from the stop signal task. Int J Yoga.;7:138-41. DOI: 10.4103/0973-6131.133896 Rajkishore Prasad , Fumitoshi Matsuno , Hovagim Bakardjian , Francois Vialatte and Andrzej Cichocki .( 2006)EEG Changes After Bhramari Pranayama.TH-F3-4.SCIS&ISIS2006 @ Tokyo, Japan (September 20-24,):390-395 Sahu KP, Kishore K. (2015)The effect of Bhramari Pranayama and Jyoti Dhyan effect on alpha EEG and Hemoglobin of college going students. Int Journal of Physical Education, Sports and Health.;1(4):40 Sharma SK, Kala N, Telles S.( 2022) Volitional yoga breathing influences attention and anxiety: An exploratory randomized crossover study. Complement Med Res.;29:120-6. DOI: 10.1159/000519715 Singh, G. (2023). Stress Among Working Women: A Literature Review. International Journal of Indian Psychology, 11(1), 176-182. DIP:18.01.019.2023110 1, DOI:10.25215/1101.019 Srivastava S, Goyal P, Tiwari S, Patel A (2017), Interventional Effect of Bhramari Pranayama on Mental Health among college Students, International Journal of Indian Psychology, Volume 4, Issue 2, No. 87, ISSN:2348-5396 (e), ISSN:2349-3429 (p), DIP:18.01.044/20170402, ISBN:978-1-365-71287-6 http://www.ijip.in | January-March, 2017 DOI: 10.25215/0402.044 Sullivan GM, Feinn R. (2012)Using Effect Size-or Why the P Value Is Not Enough. J Grad Med Educ. Sep;4(3):279-82. doi: 10.4300/JGME-D-12-00156.1. PMID: 23997866; PMCID: PMC3444174. Taneja MK. (2018)Frequency-modulated bhramari pranayam in tinnitus and deafness. Indian J Otol.;24:209-13.DOI: 10.4103/indianjotol.INDIANJOTOL_10_19 Trivedi G, Sharma K, Saboo B, Kathirvel S, Konat A, Zapadia V, Prajapati PJ, Benani U, Patel K, Shah S. (2023) Humming (Simple Bhramari Pranayama) as a Stress Buster: A Holter-Based Study to Analyze Heart Rate Variability (HRV) Parameters During Bhramari, Physical Activity, Emotional Stress, and Sleep. Cureus. Apr 13;15(4):e37527. PMID: 37193427; PMCID: PMC10182780.DOI: 10.7759/cureus.37527 https://www.deccanherald.com/business/24-of-indians-are-struggling-with-stress-report-1197723.html https://www.statista.com/statistics/1339190/india-share-of-burnout-and-distress-rate-among-employees/ https://dge.gov.in/dge/sites/default/files/2023-05/Female_Labour_Utilization_in_India_April_2023_final__1_-pages-1-2-merged__1_.pdf https://pib.gov.in/Pressreleaseshare.aspx?PRID=1805783 Source: Periodic Labour Force Survey (PLFS), July 2019- June 2020, M/o Statistics & Programme Implementation. https://www.linkedin.com/pulse/indian-women-more-stressed-than-global-counterparts-varinder-singh/ https://www.womenshealth.gov/mental-health/good-mental-health/stress-and-your-health Tables Tables 1 to 9 are available in the Supplementary Files section Additional Declarations The authors declare no competing interests. Supplementary Files CMHJTables.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5737717","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":395960382,"identity":"8b57cf21-8d44-4168-8a2a-328897721d89","order_by":0,"name":"Nidhi Khindri","email":"","orcid":"https://orcid.org/0009-0009-6397-5992","institution":"Dr.D.Y.Patil College of Ayurved and research centre Pune India","correspondingAuthor":false,"prefix":"","firstName":"Nidhi","middleName":"","lastName":"Khindri","suffix":""},{"id":395960466,"identity":"00c6398d-ed6f-4cb3-9aa0-54da92d4a980","order_by":1,"name":"Jyotsna Yadav","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABB0lEQVRIiWNgGAWjYBACxgYE24CBoYIZzJIAI9xa4LqAWs4QoQXZIgMGxja4FtyAeUby8Yc/d9gxGBw/vPEz7zzrPIMDzAdv8zBY5OG0YkZaYjPvmWQGgzNpxdK829KLDQ6wJVvzMEgU49aSY9gMco/BgRwDyZnbDiduOMBjJg3UktiAR0vjz7Z6BoPzb4x/zpwD0sL/jaCWBt62wwwGN3LMJD42gG1hw6+l51nibN624zySN56VWXw4ll4seZjN2HKOAW4thu3JBz7+bKuW4zufvPlGQo11Ht/x5oc33lTU4dYyIQFM8ygcgAgkMICjxgCHeiCQ54cqlW+AaRkFo2AUjIJRgAYAQ4FZvsZAvuoAAAAASUVORK5CYII=","orcid":"","institution":"Dr.D.Y.Patil College of Ayurved and research centre Pune India","correspondingAuthor":true,"prefix":"","firstName":"Jyotsna","middleName":"","lastName":"Yadav","suffix":""}],"badges":[],"createdAt":"2024-12-30 20:11:33","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":true,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-5737717/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5737717/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":72677232,"identity":"ebb49d77-66c6-4cb8-adcd-793f41f528f4","added_by":"auto","created_at":"2024-12-31 06:30:56","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":46318,"visible":true,"origin":"","legend":"\u003cp\u003eConsort chart\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5737717/v1/54cdee98b60e110d962e2fb1.png"},{"id":72677230,"identity":"7b396ed1-5606-458b-bd03-b028ff949032","added_by":"auto","created_at":"2024-12-31 06:30:56","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":71644,"visible":true,"origin":"","legend":"\u003cp\u003eLine graph showing total scores of Pre-test and Post-test for all 67 participants\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5737717/v1/92a6c809f7a8678ef5b5849d.png"},{"id":72679354,"identity":"9627cb13-e67a-4ce6-86f8-103d9714c519","added_by":"auto","created_at":"2024-12-31 06:55:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":391506,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5737717/v1/7a2a82c6-3b20-4707-bb79-81648ecb1cb3.pdf"},{"id":72677233,"identity":"32fbc6dc-30bd-46f8-8d3d-200076b2563d","added_by":"auto","created_at":"2024-12-31 06:30:56","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":238227,"visible":true,"origin":"","legend":"","description":"","filename":"CMHJTables.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5737717/v1/5c0d8ed5bf50a47b3f0ed98d.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eWorking Women: Their perceived stress levels and nonpharmacological yoga intervention for management\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAs stress creeps into our lives stealthily and forms a bed for all the health issues, especially mental health issues, it must be dealt with in the very initial stage. Stress is dealt with, differently by different people due to genetic makeup, early experiences, socioeconomic conditions and personality traits. Left unattended for a long period, it causes physical and mental health problems. In the span of 15-20 years, work-related stress and its harmful repercussions have increased exponentially. Work stress can be defined as the untoward reaction towards the incapability to match up one\u0026rsquo;s skills with job requirements. (Singh,2023)\u003c/p\u003e\n\u003cp\u003eAstonishingly, in the ranking of the most vulnerable population of employees, first are the child workers and second are women. Stress leads to different reactions, associated diseases and behavioral issues among workers, especially women workers. (Ornek,2020) Due to changed working scenarios and economic conditions, more difficulties have popped up in previous years for women employees who cope to maintain the work-life balance. Therefore, it is pertinent to work towards the prevention of job stress in our women force.\u003c/p\u003e\n\u003cp\u003eGlobal prevalence of stress is 36.5% (Nochaiwong,2021). According to a report called \u0026ldquo;GOQii India Fit Report 22-23\u0026rdquo; of a \u0026lsquo;Stress \u0026amp; Mental Health Study\u0026rsquo; conducted among 10,000 plus Indians, it was found that 24% of Indians are struggling with stress. Prominent stressors found to be were \u0026lsquo;workplace environment\u0026rsquo; and \u0026lsquo;financial instability.\u0026rsquo; Prevalence of Stress due to workplace among them came out to be 26% contributing factors being low salaries, long working hours, increasing competition and job insecurity; and 17% due to financial instability[1]\u003c/p\u003e\n\u003cp\u003eAnother source reported that in 2022, the prevalence of stress among employees in India was 38%[2]. Regarding the prevalence of working women in India, according to a report by Ministry of Labor and Employment 32.8% of females aged 15 years \u0026amp; above in India are participating in the labor force.[3]And the prevalence of working women in the state of Maharashtra came out to be 37.7%, with Pune city topping the charts\u003csup\u003e.[4]\u003c/sup\u003eA survey conducted by Delloitte covering 10 countries and 5,000 women showed that as compared to their global counterparts, Indian women are more stressed[5]. According to a study to assess the prevalence of anxiety and stress in Indian women, it was found that 26% were most prone and 66% were somewhat prone to stress.(Patel,2016)\u003c/p\u003e\n\u003cp\u003eIndian ancient scriptures highlight the use of Yoga in our daily life to maintain the health of mind and body through the practice of various \u003cem\u003eAsanas\u0026nbsp;\u003c/em\u003e(physical postures), \u003cem\u003epranayamas\u0026nbsp;\u003c/em\u003e(breathing techniques) and other components. \u003cem\u003ePranayama\u003c/em\u003e is a special practice that has been found to work on mental health. According to yogic texts, \u003cem\u003epranayama\u003c/em\u003e is given more importance than asana to attain good health. Different types of \u003cem\u003epranayama\u003c/em\u003e are known for their benefits. Among those various types, \u003cem\u003eBhramari Pranayam\u003c/em\u003e(BP) is one such \u003cem\u003epranayama\u003c/em\u003e which relieves stress and cerebral tension, increasing the healing capacity of the body. While performing it, the practitioner inhales and exhales through the nostrils slowly and deeply. While exhaling, a humming sound is produced like a bumble bee, through the nostrils, keeping eyes, oral cavity and ears closed by fingers in a special pose called \u003cem\u003eShanmukhi mudra\u003c/em\u003e. It strengthens and improves the voice. It induces a meditative state by harmonizing the mind and directing the awareness inward. The vibration of the humming sound creates a soothing effect on the mind and nervous system. Probable modes of action of BP on stress reduction may be due to the \u0026lsquo;humming sound\u0026rsquo; that leads to powerful visualization inwards, vibrating the head and brain due to acoustic vibrations. As a result, the cerebral cortex on getting vibrated stimulates the hypothalamus and parasympathetic nervous system. The hypothalamus controls the pituitary gland and the parasympathetic nervous system is responsible for peace and composure of mind and body. This leads to harmonious synchronization of the neuroendocrinal system.\u003c/p\u003e\n\u003cp\u003eWhile studying the literature pertaining to study topic it was found that more interventional experimental studies are required to prove with evidence, the effect of BP on stress levels. Many studies have been conducted to see its integrated effect with other yogic techniques or its add-on effect with other pharmacological interventions on various health conditions. As per our knowledge, no single study has been conducted to check the individual effect of BP solely on stress. Also, no study has been done yet to apply the above results to the population of working women. Ranking of women second to child workers in being the most vulnerable population of employees towards stress; and global prevalence of working women being 37%, draws immediate attention. \u0026lsquo;Work-related stress\u0026rsquo; takes a high toll on women\u0026rsquo;s mental health and by the time they realize that stress has overtaken them, they fall into the trap of associated health problems and their symptoms which need pharmacological interventions. And once caught into medications, it\u0026rsquo;s difficult to come out of its vicious circle of dependency, habit forming and side effects. Moreover, such medications cause hormonal imbalance, further deteriorating the condition in women leading to menstrual and reproductive problems. Furthermore, for women especially, taking medications for stress comes with a social taboo.\u003c/p\u003e\n\u003cp\u003eIt is pertinent to work towards the prevention of job stress in our women force with the help of non-pharmacological intervention. The need of the hour is to empower these women with a tool to tackle stress privately. This is an effort towards the fulfillment of Goal 3 (good health and well-being), Goal 5 (Gender Equality), Goal 8 (Decent work and economic growth), and Goal 10 (Reduced Inequalities) enlisted in the World Health Organization\u0026rsquo;s (WHO) Sustainable Development Goals (SDG). So, lifestyle modification incorporating BP as a non-pharmacological Yoga Intervention can provide an effective solution to the said problem. Therefore, this research was conducted. This study aimed to evaluate the efficacy of Bhramari Pranayam in the management of stress in working women through an instrument called the Perceived Stress Scale-10 (PSS-10) questionnaire. It was hypothesized that there is a significant difference in the mean value of the PSS-10 score before and after the intervention of Bhramari Pranayam. A self-help tool called Bhramari Pranayama Standard Operating Procedure (BPSOP) was developed, specially customized for working women. The development, validation, and pilot testing of this tool will be detailed in the subsequent publication.\u003c/p\u003e\n\u003cp\u003e[1] https://www.deccanherald.com/business/24-of-indians-are-struggling-with-stress-report-1197723.html\u003c/p\u003e\n\u003cp\u003e[2] https://www.statista.com/statistics/1339190/india-share-of-burnout-and-distress-rate-among-employees/\u003c/p\u003e\n\u003cp\u003e[3] https://dge.gov.in/dge/sites/default/files/2023-05/Female_Labour_Utilization_in_India_April_2023_final__1_-pages-1-2-merged__1_.pdf\u003c/p\u003e\n\u003cp\u003e[4] https://pib.gov.in/Pressreleaseshare.aspx?PRID=1805783 Source: Periodic Labour Force Survey (PLFS), July 2019- June 2020, M/o Statistics \u0026amp; Programme Implementation.\u003c/p\u003e\n\u003cp\u003e[5] https://www.linkedin.com/pulse/indian-women-more-stressed-than-global-counterparts-varinder-singh/\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study was approved by the institutional ethics committee (approval number:\u0026nbsp;DYPCARC/IEC/ 5 6 4/2022). The clinical trial was registered with the Clinical Trial Registry of India (CTRI) on 17\u003csup\u003eth\u003c/sup\u003e April 2023 with the registration number CTRI/2023/04/051650. This qualitative research followed the design of a Pre-test and Post-test model in a Single-arm clinical study. The recruitment of participants was done at the institution\u0026apos;s outpatient department (OPD) Consultants of the outpatient department were informed about the study who then presented it to the potential participants under their care. Three research tools were used, namely, the PSS-10 questionnaire, the developed BPSOP, and a training sheet. One piece of equipment was used namely the yoga mat.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe perceived stress scale, developed by Cohen et al. (1983), is a self-reported instrument to measure the degree to which situations in one\u0026rsquo;s life are perceived as stressful. With reliability and Cronbach\u0026rsquo;s alpha value as 0.91,it is a validated scale. Earlier it consisted of 14 items and later it was reduced to 10 item scale in 1988.Each item is scored on a 5-point scale (0 = \u0026ldquo;never,\u0026rdquo; 1 = \u0026ldquo;rarely,\u0026rdquo; 2 = \u0026ldquo;sometimes,\u0026rdquo; 3 = \u0026ldquo;often,\u0026rdquo; and 4 = \u0026ldquo;very often\u0026rdquo;), with items 4, 5,7,8, being reverse-scored items (scores 0,1,3 are reversed to 4,3,1, respectively and vice versa. The score of 2 remains unchanged). The scores of all items are added together to obtain a total score, which ranges from 0 to 40 points: the higher the score, the greater the psychological stress. scores of 0 \u0026ndash; 13 are considered low stress, 14 \u0026ndash; 26 moderate stress, and 27 \u0026ndash; 40 are high perceived stress. PSS-10 used is mentioned in table 1.\u003c/p\u003e\n\u003cp\u003eBPSOP is the standard operating procedure developed for the practice of \u003cem\u003eBhramari pranayama\u003c/em\u003e, tailored according to the needs of each working woman participant. It was tested, validated, and used as an intervention for the study group in the clinical trial. BPSOP is described in table 2.\u003c/p\u003e\n\u003cp\u003eDuring the pilot testing, it was observed that not all participants were picking up BPSOP at once. So, to prevent bias, it was decided to provide training to each participant for three days before the start of the trial. Therefore, to record the pace of acceptability of the BPSOP for each participant a training sheet consisting of different aspects of BPSOP was prepared and divided into seven items to be ticked by the researcher as and when the participant performed well. (Table 3)\u003c/p\u003e\n\u003cp\u003ePurposive Sampling was employed to recruit the participants. Recruitment was done at \u0026lsquo;Swasthavritta and Yoga\u0026rsquo; O.P.D of Dr.D.Y.Patil College of Ayurved and Research Centre, Pune, India. Consultants of the OPD were informed about the study who then presented it to the potential participants under their care. Those participants were explained about the study details and their written informed consent was sought. A pre-test was conducted using PSS-10 and scores for each participant were calculated to screen them. The selection was done according to the criteria mentioned ahead. Inclusion criteria comprised of women aged between 22 to 40 years, working for minimum 8 hours in continuation per day at a workplace, and with a score of 14-40 on PSS which form the moderate and severe stress categories. Exclusion criteria comprised of women participants with a score of less than 13 on PSS, which forms the low-stress category, known cases of severe psychological and systemic disorders, and those contra-indicated for BP, such as known cases of severe cardiovascular diseases and ear infections. Withdrawal Criteria comprised of participants who practiced non-adherence for even a single day and reported any adverse events. The sample size was calculated as 67 and the duration of study was 18 months in total including 20 days of Clinical trial. A clinical case sheet proforma about the study was prepared and used to record the selected participants\u0026apos; information and observations.\u003c/p\u003e\n\u003cp\u003eAll selected participants were allocated to the intervention of BP, for which a 3-day training was given to all in person at the institution\u0026rsquo;s yoga hall to practice different aspects of BPSOP, and their progress was recorded every day in the training sheet developed for the same. The training was followed by the session of non-pharmacological Yoga intervention of BP in 15 rounds in continuation for 20 consecutive days in the evening (30 minutes) through the online Zoom platform as per the developed, validated, and tested BPSOP. Phone calls and text messages were used as reminders for the session every day. Per-day session notes were written in a diary, mentioning the number of attendees, unintended observations, inputs, and suggestions from the participants. A post-test was conducted on the last day using the same PSS-10 and scores for each participant were calculated. Scores of the Pre-test and post-test were compared. Descriptive statistics was used to summarize and describe the data. Inferential statistics was applied to test the hypothesis using the Wilcoxon Signed rank test as the data, although normally distributed, was ordinal and discrete, and the study is based on the Pretest-Posttest model. The IBM SPSS version 21 software was used for this.The statistical significance of the result was checked through the \u0026lsquo;P-value\u0026rsquo; calculation.\u003c/p\u003e\n\u003cp\u003eThe clinical significance of the result was checked through the \u0026lsquo;Effect size\u0026rsquo; (ES) calculation. Effect sizes represent the mean change observed in a variable divided by the standard deviation of that variable. They serve to standardize \u0026quot;before and after changes\u0026quot; in a single-group context, offering a clearer and more consistent interpretation of health status outcomes. \u0026quot;Effect size as used in this study is calculated by taking the difference between the means before treatment and after treatment and dividing it by the standard deviation of the same measure before treatment. This method of calculating effect sizes can be expressed mathematically as ES = (mi - m2)/sl, where m, is the pretreatment mean, m2 the posttreatment mean, and s, the pretreatment standard deviation. In this instance the before-treatment scores are used as a proxy for control group scores. This approach treats the effect size as a standard measure of change in a \u0026quot;before and after study\u0026quot; context. We are interested in the magnitude or size of the change rather than statistical significance, so we use the standard deviation at baseline rather than the standard deviation of the difference between the means. Effect sizes can be used to translate changes in health status into a standard unit of measurement that will provide a clearer interpretation of the result\u0026rdquo; (Kazis,1989). Interpretation of effect size was done according to Cohn\u0026rsquo;s Standard classification (Sullivan,2012) (Table 4)\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 100 people were screened for eligibility. Out of these, 69 were selected as per the inclusion criteria. The remaining 31 were excluded as they had a score of less than 13 on PSS-10. All 69 were allocated to the intervention who started BP sessions. 2 participants were withdrawn due to non-adherence after 5 days from the start of the intervention session. Analysis was done for the remaining 67 participants. The consort chart is given in Figure 1.\u003c/p\u003e\n\u003cp\u003eThe participants\u0026rsquo; demographics and other characteristics are shown in Table 5.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe total scores on PSS-10 for all 67 participants were compared through a Pre-test (Before BP intervention) and a post-test (after BP intervention), shown in Figure 2.\u003c/p\u003e\n\u003cp\u003eParticipants were numbered according to different stress categories before and after the BP Intervention. It was concluded that the before and after numbers for the low-stress category were 0 and 28, respectively. Before and after numbers for the moderate stress category were 52 and 39, respectively. The before and after numbers for high stress category were 15 and 0, respectively. (Table 6)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnalysis of responses to each question of PSS-10 was done and summarized in Table 7.\u003c/p\u003e\n\u003cp\u003eAs, each type of response in PSS-10 has got a score value like 0 for \u0026lsquo;Never\u0026rsquo;, 1 for \u0026lsquo;Almost never\u0026rsquo;, 2 for \u0026lsquo;Sometimes\u0026rsquo;, 3 for \u0026lsquo;Fairly often\u0026rsquo;, and 4 for \u0026ldquo;Very often\u0026rsquo;, scores for \u0026lsquo;before \u0026amp; after\u0026rsquo; responses of all 67 participants to each question were totaled and the values of mean, standard deviation were calculated. Thereafter, using the Wilcoxon Signed Rank test, Z and P-values were calculated. Finally, the percentage effect was computed. The same was done for total scores too. The summary of statistics is given in Table 8.\u003c/p\u003e\n\u003cp\u003eThe mean score values decreased remarkably after the intervention for each question and the total score, and all the p-values came out to be less than 0.05. Also, the intervention had a notable percentage of effect on the response score for each question. Therefore, it was deduced that the results are statistically significant and there is strong evidence to reject the null hypothesis, i.e. \u0026ldquo;There is no significant difference in the mean value of PSS score before and after the intervention of \u003cem\u003eBhramari Pranayam\u003c/em\u003e.\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe effect size of 1.7 was calculated by taking the difference between the means before treatment and after treatment and dividing it by the standard deviation of \u0026lsquo;before treatment\u0026rsquo; using the formula ES = (m1 - m2)/s where m1 is the pretreatment mean, m2 the posttreatment mean, and s is the pretreatment standard deviation. Therefore, ES= 22.5075-14.28366/4.806481, which gives the value of 1.7. According to Cohn\u0026rsquo;s Standard classification, an effect size of 1.7 indicates that the mean of the post-treatment is at the 95.5 percentile of the Pre-treatment. Hence, it was concluded that the effect of the intervention had a large magnitude, which implies that the results are clinically significant. The result analysis is summarized in Table 9.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we evaluated the efficacy of BP in managing the perceived stress levels of working women and it was inferred that BP through BPSOP is effective in reducing stress. Stress forms the bed for all kinds of health issues, so it\u0026rsquo;s important to nip it in the bud as it gradually progresses into severe medical conditions if left untreated.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe reason behind choosing women as the target population in this study was that women are twice as likely as men to develop symptoms of stress.[6] Hammen et al. (2009) reported that women are more prone to mental health problems that worsen due to stress, anxiety and depression. Among women, those who are working are more prone to stress (Joseph,2019). Second, only to child workers, women are the most vulnerable population of employees. Panigrahi (2017) says that Job stress is known as the \u0026ldquo;illness of the century.\u0026rdquo; Singh (2023) revealed that the majority women are dealing with higher levels of occupational stress. Another study by Gyllensten (2005) found that as compared to men, a higher level of stress is faced by working women; Common stressors came out to be work overload, juggling of multiple roles, stereotyping and discriminatory practices; \u0026lsquo;Role overload\u0026rsquo; is a significant stressor for working women as they have to play different roles at the workplace and with family and most of them are unable to do equal justice at both the places which leads to fatigue, disappointment, and stress. A prolonged stressful phase leads to the development of symptoms like headache, hypertension, obesity and even stroke. Stress is also termed the silent serpent for working women (Lakhute et al. 2024). While exploring intervention methods to manage stress, it was found that non-pharmacological interventions (NPI) being cost-effective can be the potential solution for better living, preventing disease, and self-care. Among the NPI, Yoga was chosen due to factors like its \u0026lsquo;ease of doing\u0026rsquo; irrespective of time and place, maintaining privacy, and less time-consuming, considering the hectic schedules of working women and time paucity to make self-care efforts. In Yoga too, \u003cem\u003ePranayayam\u003c/em\u003e was chosen due to its simple technique, short duration, and amplified results for the improvement of mental health. From among various \u003cem\u003ePranayams\u003c/em\u003e, \u003cem\u003eBhramari\u003c/em\u003e was the choicest kind due to its scientifically proven effect on stress and other compromised mental health conditions. The current scenario of our busy schedules does not allow us to focus on our physical health leave apart mental health. So, the BP Procedure was designed meticulously and customized thoughtfully in the form of BPSOP to cater to busy working women. It was kept easy to grasp, short, crisp, easy to self-perform, and to apply in routine throughout life. Dividing the rounds into sets with breaks in between made it comprehensible and acceptable to the women participants.\u003c/p\u003e\n\u003cp\u003eStress scores when evaluated according to age, it was found that 31.3% belonged to the age group 26-30 years, followed by 25.4% ,17.9% that belonged to age groups 21-25years, and 31-35 years respectively. And for the age group of 36-40 years, another 25.4% was recorded. This shows that the age between 26-30 years is the most stressful phase for working women, probable reasons being marriage aspect, career prospects, family planning, etc. as these years are the formative years of the above factors. A study by Jeganathan K (2019) conducted to check relation between age and occupational stress revealed that age plays a pivotal contributor towards stress in women who are working, showing women of age 45 years and above, (which was excluded in our study for the possibility of being known cases of various diseases) face more stress as compared to other age groups followed by women of the group 25-34 years, which coincides with our result. Another study to evaluate stress in working women showed women in age group 18-25 years deal with stress the most, which is different from that of ours. Among the occupations included in the study, Physicians stand out as the largest number of participants contributing to almost 20% for the relation of occupation and stress in working women. Research done on Perceived stress of women health care workers showed a high prevalence of stress in the mentioned sector, which strengthens our finding (Prashar M.et al.2017). Among the women studied here, 45 were married and 22 were unmarried showing the high incidence of perceived stress in women who are married and working. Different but not far were the results of the study of Prashar M.et al.(2017) \u0026nbsp;in which out of 64 respondents,31 were married and 33 were unmarried who were working and dealing with stress. Another research by Panigrahi (2014) also revealed similar results that married women are experiencing more stress than unmarried women due to traditional trends, demands of society and more roles and responsibilities assigned to them as a mother, wife and homemaker.\u003c/p\u003e\n\u003cp\u003ePSS-10 judges an individual on three parameters i.e. total scores, helplessness and lack of self-efficacy. Higher scores represent higher levels of stress. In PSS there are two subscales of helplessness and lack of self-efficacy. Question numbers 1,2,3,6,9,10 measure individual\u0026rsquo;s lack of control over circumstances or their reactions. Question numbers 4,5,7,8 measure an individual\u0026rsquo;s inability to handle problems. As PSS deals with an individual\u0026rsquo;s perception of stress and its subscales measure one\u0026rsquo;s perception of helplessness and lack of self-efficacy, accordingly interpretation of mean scores, p-values and their percentage effect per question of PSS have been discussed ahead along with the probable mode of action of BP on each one of it. To begin with, first question deals with one\u0026rsquo;s lack of control over some unexpected happening. The mean score of its responses before and after intervention was 2.4478 and 1.2687, respectively. A significant reduction in the mean scores, before and after Bhramari practice, to nearly half reflects improved control over circumstances. Also depicted that participants were 48% more capable of dealing with unexpected or untoward circumstances positively. Probable reasons for such a result could be that Bhramari practice increases the production of nitric oxide (NO) in the body (Kumar,2021). And NO is known to inhibit the production of Cortisol - the stress hormone. Particularly, the humming sound produced during the exhalation phase of BP ramps up the generation of NO by 15-fold as compared to quiet exhalation. Thus improving one\u0026rsquo;s reaction towards unexpected happenings (Rajesh 2014). Also, Bhramari practice shortens reaction time which means improvement in information processing and reflexes, resulting in improved cognitive function (Kuppusamy \u0026nbsp;et al. 2021). The second question checks one\u0026rsquo;s control over important things in one\u0026apos;s life. The mean scores of its responses before and after intervention were 2.6716 and 1.4925, respectively. Here too, a comparison of before and after mean scores shows a reduction to approximately half and their difference shows that participants were 44% more capable of asserting control over their life\u0026rsquo;s important things. Probable reasons can be that Acoustic Vibration produced by the humming sound stimulates brain tissues (Chetry et al.2024). Also, BP activates the parasympathetic nervous system leading to a calmer state of mind which helps in prioritizing important things of life (Ismail et al.2022). The third question deals with one\u0026rsquo;s frequency of feeling nervous and stressed. The mean scores of its responses before and after intervention were 2.6716 and 1.5522, respectively. Again, mean scores show a reduction to nearly half, post-intervention showing that the frequency of feeling nervous and stressed by the participants reduced by 42%, which is a remarkable finding. As Bhramari Pranayam increases the activity of the parasympathetic nervous system, decreasing that of the sympathetic nervous system, which in turn decreases cardiovascular parameters like blood pressure and heart rate which lead to a reduced nervous and stressed state of mind (Kuppusamy et al.2016). Also, Bhramari leads to bliss kind of feeling in an individual (Kuppusamy et al.2017). According to a study, Bhramari is a relaxation technique that works on neuromodulating principles to reduce stress and anxiety, supporting our findings (Pandey et al.2010). So, a person\u0026rsquo;s perceived ability to handle problems is boosted. The fourth question asks the subjects about the frequency of their feeling confident for their ability to handle personal problems. The mean scores of its responses before and after intervention were 1.3433 and 1.1194, respectively. Difference in the mean scores show that their confidence in themselves increased by 17%. According to a few clinical control trials, practicing Bhramari even for a short duration improves attention performance significantly (Kala et al.2023, Sharma et al. 2022, Pradhan et al.2018). Another single-group clinical study concluded that practicing BP for a short term resulted in a considerable rise in alpha-EEG (Trivedi et al.2023). And alpha waves are associated with bringing about a state of deep relaxation. These results may be the probable reasons behind our finding on this particular question. The fifth question deals with the perception of subjects regarding taking things as favorable to their way. The mean scores of its responses before and after intervention were 1.9254 and 1.4478, respectively. Differences in the mean scores reflect that intervention had a positive effect on the perceived ability to deal with problems. The percentage effect came out to be 24.81%. This finding gets weightage by the result of a study that says the humming sound created during exhalation generates the lowest stress index when compared to other activities like physical activity, emotional stress and sleep. It can be a strong stress buster. A regular daily humming routine can enhance parasympathetic activity leading to the normalcy of stress hormones which helps in positively tackling things (Trivedi et al., 2023). Another study concluded that the practice of BP improves the feeling of physical and mental well-being (Beldar S et al. 2020) .These findings coincide with and support our results.\u003c/p\u003e\n\u003cp\u003eThe sixth question examines the subjects for their helplessness frequency to cope with their tasks. The mean scores of its responses before and after intervention were 2.4925 and 1.5821, respectively. Mean scores showed a reduction post-intervention and around 37% decrease was seen on average, in the perceived lack of control over circumstances. A study conducted to find the effect of BP on physical and physiological parameters among cricketers concluded that its practice improves cardio-respiratory endurance; increases speed, flexibility, vital capacity, and haemoglobin percentage; and reduces pulse rate, blood pressure and respiration rate of resting state (Pratap et al.2017). It provides evidence and support for our findings. Due to all the above, we can conclude that subjects feel empowered to tackle their tasks. The seventh question speaks about the amount of self-efficacy of participants to control irritations in their lives. The mean scores of its responses before and after intervention were 1.7015 and 1.3433, respectively. A reasonable difference in pre and post-mean values of responses was noticed showing a 21% increase in the ability of the participants to deal with irritations. According to Kuppusamy et. al (2016) BP has an instant calming effect, relieving anger, stress, and anxiousness. Also, it concludes that Bhramari practice releases hormones linked with the state of joyfulness and peace like endorphin and encephatin. It decreases dopamine secretion which is known as the stress hormone. This mechanism may be the probable reason to support our finding. Moving on to the next eighth question, which asks about the frequency of feeling on top of things. The mean scores of its responses before and after intervention were 2.1194 and 1.4627, respectively. Mean value changes in its responses are decent showing around a 31% increase in the capability of the participants to feel that way. A study concluded that humming sound enhances the resonance of mind, forming vibrations in the brain that elevate positive mood in an individual (Srivastava et al. 2017). This breathing pattern enables a person to gain full control of one\u0026rsquo;s mind and emotions. This result coincides with our findings. A study on brain wave frequency and BP stated that due to bhramari practice gamma waves are found to be positively affected and that is significant as it reflects the increased activity of multiple areas of the brain simultaneously, which makes a person feel on top of the things (Prasad et al. 2006). The ninth question on PSS judges the perceived incapability of subjects to control their anger. The mean scores of its responses before and after intervention were 2.7910 and 1.6716, respectively. In this question, responses showed a marked change in pre and post-mean values, reflecting that their ability to deal with anger increased by 40%. This finding may be backed by the results of the study which says that bhramari practice alleviates aggression by producing vibrations in the mind through which the hypothalamus and pituitary glands are controlled to eliminate anger. Stimulation of the autonomous nervous system increases the secretion of the noradrenalin hormone which in turn reduces the secretion of hormones related to anger and anxiousness (Srivastava et al 2017). This is how Bhramari may be working in bringing about changes to the responses to the said questions. The tenth and last question deals with the incapability of subjects to deal with piled-up difficulties which form a roadblock for them. The mean scores of its responses before and after intervention were 2.3433 and 1.3433, respectively. There was a significant difference in the mean scores before and after intervention. The marked effect was seen in percentage effect too, showing around 43% positive change in the ability of the participants to deal with difficult tasks. A study conducted by Prasad et al.( 2006) to see changes in the pattern of EEG after practicing bhramari pranayam revealed that bhramari produces quick changes in all brain wave signals of delta, theta, alpha, beta and gamma frequencies. \u0026nbsp;Results of above-mentioned study provides evidence to our finding. It concludes that a simultaneous positive effect on all brain wave patterns leads to remarkable and profound ability of an individual to perform complex task. Delta waves open the gateway of learning and increase intuition and creativity. Theta improves sleep; Alpha takes one into deep relaxing state; Beta increases alertness and visual sharpness and lastly gamma helps accomplish difficult and complex tasks involving multiple areas of brain.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOverall effect of BP is reflected in the mean values of total scores of PSS. The mean values of total score before and after intervention were 22.5075 and 14.2836, respectively. Marked changes were seen in Pre and post-total scores. The mean value for post scores was reduced and a significant p-value of 0.000 was calculated, reflecting around 37% positive overall effect in stress reduction due to BP. Results of various studies conducted on brain wave patterns support our finding which revealed that Bhramari alters EEG data in the frontal \u0026amp; temporal regions of the brain, causes symmetric activation in the prefrontal region and strengthens synchronization of the temporal lobe (Jin et al.2014,Prasad and Matsuno.2007,Prasad et al.2007). A study by Sahu (2015) reported a considerable rise in alpha EEG after Bhramari practice for a short duration.Few other studies concluded that Bhramari practice improves attention performance(Kala et al.2023, Sharma et al.2022,Pradhan et al.2018). Studies conducted on stress reduction revealed marked changes in stress levels(Jagadeesan et al.2022,Kumar 2021, Maheshkumar 2022) . Various other studies proved improvement in sleep quality(Jagadeesan et al.2022,Kumar 2021, Bhati et al.2017); quality of life (Jagadeesan et al.2022,taneja 2018); and overall mental health(Srivastava et al.2017). Furthermore, many other studies conducted to prove the result of Bhramari on cardiovascular functions, pulmonary functions, neuro-endocrine functions reveal that the synergistic effect of all mentioned above breaks the patho-physiology of stress.\u003c/p\u003e\n\u003cp\u003eOne unintended observation was recorded as one participant complained of being shaky and drained on 3rd day after taking the intervention. For that reason, she was asked to check blood pressure readings from the 4th day onwards before and after the session. It was observed that Bhramari practice had a normalizing effect on Blood pressure readings for that participant, i.e., if Blood pressure was a little more than the normal range of Diastolic/systolic \u0026nbsp;(120/80 mmHg ) before intervention, it got normalized after intervention and vice- versa. Previous studies like Single-group clinical trials, as well as clinical control trials with very short- to short-term follow-up periods, revealed increased heart rate, total peripheral resistance, diastolic blood pressure, and mean arterial pressure with a significant reduction in pulse interval, stroke volume, and cardiac output during BP. Following the practice, there were significant drops in heart rate, pulse rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, rate-pressure product and double product (Chetry et al.2024, Latha 2022).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSome strengths and limitations were identified in our research. The single-arm design of the study limited the scope of comparison in the absence of control. The small sample size enabled an in-depth analysis but restricted the range of effectiveness. The online platform chosen to provide the intervention might have brought in the bias. After conducting the pilot study, it was identified as a compulsion in this case, considering the working nature and different work timing of the participants.\u0026nbsp;\u003c/p\u003e\n\u003cdiv id=\"ftn1\"\u003e\n \u003cp\u003e[6] https://www.womenshealth.gov/mental-health/good-mental-health/stress-and-your-health\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe present study aimed at evaluating the efficacy of Bhramari Pranayama on the stress levels of working women through the PSS scores showed that after 20 days of practice of bhramari pranayam, there was a significant reduction in the stress levels of working women. The mean of the post-treatment is at the 95.5 percentile of that of the Pre-treatment, showing the clinical significance of the intervention. The mean of the total score, pre-intervention, was 22.5075 and the mean of the total score, post-intervention, was 14.2836, showing a marked difference in the values. The calculated p-value came out to be .000, which is less than 0.05 and is statistically significant. Individually, too, for all ten questions of PSS, the p-value came out to be less than 0.05. Therefore, it can be inferred that Bhramari pranayam is effective in managing the stress levels of working women. The results of this study can be applied in the future to see the changes in hormonal profiles and stress markers (serum cortisol, alpha amylase). The same effect can be evaluated by targeting different populations to mitigate stress. Results from further randomized control trials are required to translate the findings of this study. Developed BPSOP can prove to be a ready tool for self-help and further research. This is an effort in line with goal 3 (good health and well-being), goal 5 (Gender Equality), goal 8 (Decent work and economic growth), and goal 10 (Reduced Inequalities) enlisted under the SDG of WHO.\u003c/p\u003e"},{"header":"Statements and Declarations","content":"\u003cp\u003eFunding:The authors did not receive support from any organization for the submitted work.\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003eEthics approval:This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Institutional Ethics Committee of Dr.D.Y.Patil College of Ayurved and Research centre (Date-\u0026nbsp;05/08/2022/No.-DYPCARE/IEC/564/2022).\u003c/p\u003e\n\u003cp\u003eClinical Trial Registration: Date-17/04/2023; CTRI No.-CTRI/2023/04/051650\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent to participate:\u0026nbsp;Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003eAuthors’ contribution statements: All authors contributed to the study’s conception and design. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAshok panigrahi.Jan (2017).Managing Stress at Workplace.Journal of Management Research and Analysis, October-December,2016;3(4):154-160.\u003c/li\u003e\n \u003cli\u003eBeldar S, Bhati K. (2020) Evolution of bhramari pranayam in the management of menopausal syndrome. 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PMID: 27437210; PMCID: PMC4948385.doi: 10.7860/JCDR/2016/19202.7894\u003c/li\u003e\n \u003cli\u003eLakhute, S. vitthalrao ., Band, R. M. . and Rajasekaran, P. K. (2024) \u0026ldquo;Stress Among Working Women: A Silent Serpent\u0026rdquo;, National Journal of Community Medicine, 15(06), pp. 509\u0026ndash;510. doi: 10.55489/njcm.150620243895.\u003c/li\u003e\n \u003cli\u003eLatha R, Lakshmi SS. (2022)A study on immediate and training effect of bhramari pranayama on heart rate variability in healthy adolescents. Biomedicine.;42:784-8.DOI: https://doi.org/10.51248/.v42i4.1501\u003c/li\u003e\n \u003cli\u003eMaheshkumar K, Dilara K, Ravishankar P, Julius A, Padmavathi R, Poonguzhali S, et al. (2022)Effect of six months pranayama training on stress-induced salivary cortisol response among adolescents-randomized controlled study. Explore (NY).;18:463-6 DOI: 10.1016/j.explore.2021.07.005\u003c/li\u003e\n \u003cli\u003eNochaiwong S, Ruengorn C, Thavorn K, Hutton B, Awiphan R, Phosuya C, Ruanta Y, Wongpakaran N, Wongpakaran T. (2021).Global prevalence of mental health issues among the general population during the coronavirus disease-2019 pandemic: a systematic review and meta-analysis. Sci Rep. 2021 May 13;11(1):10173. PMID: 33986414; PMCID: PMC8119461.doi: 10.1038/s41598-021-89700-8\u003c/li\u003e\n \u003cli\u003ePandey, N.K. Mahato, R. Navale (2010).Role of self-induced sound therapy: bhramari pranayama in tinnitus Audiol Med, 8 (3), pp. 137-141 DOI: 10.3109/1651386X.2010.489694\u003c/li\u003e\n \u003cli\u003ePanigrahi, A., Padhy, A. P., \u0026amp; Panigrahi, M. (2014). Mental health status among married working women residing in Bhubaneswar city, India: a psychosocial survey. BioMed research international, 2014, 979827. https://doi.org/10.1155/2014/979827\u003c/li\u003e\n \u003cli\u003ePatel PA, Patel PP, Khadilkar AV, Chiplonkar SA, Patel AD.(2017)Impact of occupation on stress and anxiety among Indian women. Women Health. Mar;57(3):392-401. doi: 10.1080/03630242.2016.1164273. Epub 2016 Mar 16. PMID:26984269. DOI: 10.1080/03630242.2016.1164273\u003c/li\u003e\n \u003cli\u003ePradhan B, Mohanty S, Hankey A.(2018) Effect of yogic breathing on accommodate braille version of six-letter cancellation test in students with visual impairment. Int J Yoga.;11:111-5.DOI: 10.4103/ijoy.IJOY_40_17\u003c/li\u003e\n \u003cli\u003ePrasad R, Bakardjian H, Cichocki A, Matsuno F. (2007 )Source localization with EEG data for BP shows major activities in the frontal areas of the brain. InSICE Annual Conference 2007 Sep 17 (pp. 774-778). IEEE.DOI: 10.1109/SICE.2007.4421087\u003c/li\u003e\n \u003cli\u003ePrasad R, Matsuno F. (2007) Hummgenic changes in large scale temporal correlation of EEG in BP. InSICE Annual Conference 2007 Sep 17 (pp. 2068-2073). IEEE.DOI: 10.1109/SICE.2007.4421328\u003c/li\u003e\n \u003cli\u003ePratap Bhushan, Kunwar Bipin \u0026amp; Nathani, Neeru \u0026amp; Tripathi, Narendra. (2017). Impact of Bhramari Pranayama on Cardio Respiratory Endurance among the Cricket Players with Special Reference to Prakriti (Psycho-somatic Constitution).International Journal of Physical Education and Sports.Volume: 2, Issue: 9, Pages: 08-13\u003c/li\u003e\n \u003cli\u003eRajesh SK, Ilavarasu JV, Srinivasan TM. (2014) Effect of bhramari pranayama on response inhibition: Evidence from the stop signal task. Int J Yoga.;7:138-41. DOI: 10.4103/0973-6131.133896\u003c/li\u003e\n \u003cli\u003eRajkishore Prasad , Fumitoshi Matsuno , Hovagim Bakardjian , Francois Vialatte and Andrzej Cichocki .( 2006)EEG Changes After Bhramari Pranayama.TH-F3-4.SCIS\u0026amp;ISIS2006 @ Tokyo, Japan (September 20-24,):390-395\u003c/li\u003e\n \u003cli\u003eSahu KP, Kishore K. (2015)The effect of Bhramari Pranayama and Jyoti Dhyan effect on alpha EEG and Hemoglobin of college going students. Int Journal of Physical Education, Sports and Health.;1(4):40\u003c/li\u003e\n \u003cli\u003eSharma SK, Kala N, Telles S.( 2022) Volitional yoga breathing influences attention and anxiety: An exploratory randomized crossover study. Complement Med Res.;29:120-6. DOI: 10.1159/000519715\u003c/li\u003e\n \u003cli\u003eSingh, G. (2023). Stress Among Working Women: A Literature Review. International Journal of Indian Psychology, 11(1), 176-182. DIP:18.01.019.2023110 1, DOI:10.25215/1101.019\u003c/li\u003e\n \u003cli\u003eSrivastava S, Goyal P, Tiwari S, Patel A (2017), Interventional Effect of Bhramari Pranayama on Mental Health among college Students, International Journal of Indian Psychology, Volume 4, Issue 2, No. 87, ISSN:2348-5396 (e), ISSN:2349-3429 (p), DIP:18.01.044/20170402, ISBN:978-1-365-71287-6 http://www.ijip.in | January-March, 2017 DOI: 10.25215/0402.044\u003c/li\u003e\n \u003cli\u003eSullivan GM, Feinn R. (2012)Using Effect Size-or Why the P Value Is Not Enough. J Grad Med Educ. Sep;4(3):279-82. doi: 10.4300/JGME-D-12-00156.1. PMID: 23997866; PMCID: PMC3444174.\u003c/li\u003e\n \u003cli\u003eTaneja MK. (2018)Frequency-modulated bhramari pranayam in tinnitus and deafness. Indian J Otol.;24:209-13.DOI: 10.4103/indianjotol.INDIANJOTOL_10_19\u003c/li\u003e\n \u003cli\u003eTrivedi G, Sharma K, Saboo B, Kathirvel S, Konat A, Zapadia V, Prajapati PJ, Benani U, Patel K, Shah S. (2023) Humming (Simple Bhramari Pranayama) as a Stress Buster: A Holter-Based Study to Analyze Heart Rate Variability (HRV) Parameters During Bhramari, Physical Activity, Emotional Stress, and Sleep. Cureus. Apr 13;15(4):e37527. PMID: 37193427; PMCID: PMC10182780.DOI: 10.7759/cureus.37527\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"1\"\u003e\n\u003cli\u003ehttps://www.deccanherald.com/business/24-of-indians-are-struggling-with-stress-report-1197723.html\u003c/li\u003e\n\u003cli\u003ehttps://www.statista.com/statistics/1339190/india-share-of-burnout-and-distress-rate-among-employees/\u003c/li\u003e\n\u003cli\u003ehttps://dge.gov.in/dge/sites/default/files/2023-05/Female_Labour_Utilization_in_India_April_2023_final__1_-pages-1-2-merged__1_.pdf\u003c/li\u003e\n\u003cli\u003ehttps://pib.gov.in/Pressreleaseshare.aspx?PRID=1805783 Source: Periodic Labour Force Survey (PLFS), July 2019- June 2020, M/o Statistics \u0026amp; Programme Implementation.\u003c/li\u003e\n\u003cli\u003ehttps://www.linkedin.com/pulse/indian-women-more-stressed-than-global-counterparts-varinder-singh/\u003c/li\u003e\n\u003cli\u003ehttps://www.womenshealth.gov/mental-health/good-mental-health/stress-and-your-health\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 9 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Dr.D.Y.Patil college of Ayurved and Research Centre Pune India","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Working women, Stress, Mental health, Yoga, Bhramari Pranayama, SDG","lastPublishedDoi":"10.21203/rs.3.rs-5737717/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5737717/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003cbr\u003e\nWork-related stress significantly impacts women’s mental health, leading to associated health issues requiring pharmacological interventions. With 37% of working women globally affected by stress, effective and accessible interventions are urgently needed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e\u003cbr\u003e\nTo evaluate the efficacy of Bhramari Pranayama (BP) in managing stress among working women using the Perceived Stress Scale-10 (PSS-10) and a validated self-help tool: Bhramari Pranayama Standard Operating Procedure (BPSOP).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003cbr\u003e\nA single-arm clinical trial was conducted on 67 women aged 22–40 years with moderate to severe stress (PSS scores: 14–40). Exclusion criteria included low-stress scores (\u0026lt;13), severe psychological or systemic disorders, cardiovascular diseases, and ear infections. Participants underwent a 3-day in-person BP training followed by 20 days of intervention via the online Zoom platform. BP was practiced for 30 minutes daily (15 rounds) in the evenings. Pre- and post-intervention PSS-10 scores were compared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003cbr\u003e\nThe mean pre-intervention PSS score was 22.51, while the post-intervention mean was 14.28, showing a significant reduction. The calculated p-value (.000) was statistically significant, and the effect size (1.7) indicated a large magnitude of improvement, with post-intervention scores at the 95.5 percentile of pre-intervention values.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003cbr\u003e\nBhramari Pranayama is effective in reducing stress among working women. This effort is in line with Sustainable Development Goal (SDG) number 3 and highlights the need for action towards the fulfillment of SDG 5,8,10. \u0026nbsp;Limitations include the single-arm design, small sample size, and online delivery. Future studies can explore its impact on hormonal stress markers and expand the findings through randomized controlled trials. The validated BPSOP tool offers a promising, accessible self-help intervention for stress management. The clinical trial was registered with the Clinical Trial Registry of India (CTRI) on 17\u003csup\u003eth\u003c/sup\u003e April 2023 with the registration number CTRI/2023/04/051650.\u003c/p\u003e","manuscriptTitle":"Working Women: Their perceived stress levels and nonpharmacological yoga intervention for management","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-31 06:30:51","doi":"10.21203/rs.3.rs-5737717/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5eaeb638-0e05-4ece-8762-fb6d6f2bffca","owner":[],"postedDate":"December 31st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":42191823,"name":"Preventive Medicine"},{"id":42191824,"name":"Women's studies"}],"tags":[],"updatedAt":"2024-12-31T06:30:51+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-31 06:30:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5737717","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5737717","identity":"rs-5737717","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}