Improving mental health and self-efficacy in older people through a mindfulness-based community intervention

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With the global population ageing, there is a growing demand for interventions tailored to address their specific mental health problems and improve their overall well-being. This study aimed to assess the effectiveness of a mindfulness-based community intervention on mental health and self-efficacy in older individuals. The study involved 257 participants who were divided into an intervention and a control group. Assessments were conducted at the beginning and 6 months after its completion. The results revealed a significant reduction in depression within the intervention group (p <.001). Furthermore, the intervention led to significant improvements in general self-efficacy, chronic disease self-management self-efficacy, physical activity and nutrition self-efficacy within the intervention group compared to the control group. Overall, the results demonstrate the effectiveness of mindfulness-based community interventions in improving mental health and self-efficacy in older people in community settings. The results of the present study showed that this programme resulted in immediate health benefits in terms of mental health and self-efficacy of older people, while giving a contribution to the development of effective strategies for chronic disease self-management. Health sciences/Health care/Public health Health sciences/Health care/Quality of life mental health self-management self-efficacy mindfulness public health Introduction Ageing is diverse and complex and includes a multitude of biological, psychological and social changes that become a part of the experience of growing older [ 1 ]. Examples include vulnerability to stress, loss of self-efficacy and loss of mental health (all often exacerbated by age-related problems such as physical health issues and cognitive deterioration and social isolation) [ 1 ]. With the growing age structure of the world’s population, attention to mental wellbeing for older people is becoming a vital consideration for the delivery of evidence-based mental health intervention into the future considering well-being and quality of life of older people. Mental health is an essential component of overall health. It encompasses emotional, psychological and social well-being and enables the individual to successfully cope with the complexities and challenges of life [ 2 ]. A healthy mind is characterised by maintaining fulfilling relationships, coping with stress, feeling satisfied and coping with change or difficulties [ 3 ]. Maintaining mental health is particularly important for older individuals who are struggling with age-related issues such as cognitive decline, physical difficulties and social isolation [ 4 ]. Numerous factors, including biological aspects such as genetic predispositions and changes in brain chemistry, influence the onset and progression of mental health problems in older people [ 5 ]. In addition, psychological factors such as personality traits and coping mechanisms play an important role in how people respond to stress and adversity [ 6 ]. The mental health of older people is also influenced by social variables, including social support, financial resources and cultural aspects [ 7 ]. Understanding and managing these various factors that influence the mental health of older people is becoming increasingly important as the world's population ages. Older people often suffer from mental health problems such as depression and anxiety. According to research data, 20% of people over the age of 60 suffer from mental health problems [ 8 ]. These problems can lead to a higher level of disability, a poorer standard of living and an increase in healthcare costs [ 9 ]. In addition, older people's mental health problems are often not properly recognised and treated, exacerbating the impact on individuals and society as a whole [ 10 ]. In addition to mental health, chronic diseases as a physical component of health are the main cause of disability and mortality in older people [ 11 ]. Most older individuals suffer from multiple chronic conditions that can affect their quality of life. In addition, the increasing prevalence of chronic conditions is linked to physical functioning and a significant increase in healthcare costs. To cope with this burden, older people can acquire new life skills to effectively self-manage their illnesses [ 12 ]. Self-efficacy is a psychological concept that refers to a person's confidence in their ability to perform a particular task or behaviour [ 13 ]. This important element influences motivation, persistence and resilience and is associated with several positive outcomes, including better stress management, better mental health and higher life satisfaction [ 14 ]. Fostering a strong sense of self-efficacy can help older people overcome the obstacles of ageing, maintain their independence, adapt to changing roles and responsibilities and maintain a good quality of life [ 15 ]. Mindfulness as a state of mind characterised by non-judgemental observation of the present moment [ 16 ] has attracted much attention for its potential to promote mental health and resilience. Rooted in ancient Buddhist philosophy, mindfulness practices such as meditation, body scans, and mindful exercises like yoga aim to enhance present-moment awareness, offering psychological and physical benefits [ 17 , 18 ]. Studies consistently show that mindfulness practises improve psychological well-being by reducing symptoms of depression, anxiety and stress [ 19 ] while improving self-compassion, life satisfaction and emotional regulation [ 20 ]. In terms of stress reduction, mindfulness promotes adaptive coping mechanisms such as problem solving, emotion control and cognitive reorganisation, which helps people to better manage stress and respond to stressors [ 21 ]. In addition, mindfulness practises are also associated with increased self-efficacy by promoting greater self-awareness, self-compassion and a more accurate understanding of one's own abilities and limitations [ 22 ]. The aim of the study was to investigate the effectiveness of a seven-week mindfulness-based community intervention on mental health and self-efficacy in older people. This seven-week mindfulness-based workshop programme combines the theoretical framework of salutogenesis, the person-centred approach, positive psychology, behaviour change theory based on the Transtheoretical Model, mindfulness, the GROW coaching model (Goal, Reality, Options, and Will model) and two already known evidence-based programmes: The Chronic Disease Self-Management Programme (CDSMP) and the Mindfulness-based Living Programme [ 23 – 25 ]. Materials and Methods While conducting the study, the study participants were divided into two groups. The first consisted of the participants who took part in a mindfulness-based intervention and the second was the control group. The participants were residents of the city of Rijeka and the wider urban area. Inclusion in each group was based on the geographical location of the participants and their GPs/community patronage nurses. The first patients to visit their GP or community patronage nurses and considering the inclusion and exclusion criteria, the research has been presented after which they decided whether they wanted to participate in the study. In line with the research methodology, participants were given the option to take part in either the intervention or the control group. Inclusion criteria for participants were persons of both sexes, older than 65 years, presence of a chronic disease such as cardiovascular diseases/condition (heart failure, hypertension) and/or diabetes type II, residing in the city of Rijeka and the wider urban area, and able to participate in the study for a period of 6 months. On the other hand, the exclusion criteria were the following: persons who do not have a permanent residence in the city of Rijeka and the wider urban area, persons who were not able to participate in the study for 6 months (persons planning to travel for a longer period of time or terminally ill patients), persons who are without a home, persons suffering from a mental illness according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV), persons with cognitive impairments and addicts of alcohol and other addictive substances. This pretest-post-test non-equivalent groups design research study was conducted from 1 October 2019 to 15 August 2022, during which time the intervention participants attended the seven-week workshop programme. The workshops were organised so that participants were divided into smaller groups of up to 10 people and lasted 2 hours while respecting all epidemiological measures which were active during the Coronavirus disease 2019 (COVID-19) pandemic. The aim of the seven-week workshop programme, led by trained workshop facilitators, was to induce behaviour change in the participants, make them aware of their habits and lifestyle, and reduce the risk factors that are modifiable: obesity, unhealthy diet, physical inactivity, harmful alcohol consumption, tobacco use, and learning new skills to improve self-efficacy, self-esteem and the ability to self-manage their health. In addition, the programme of workshops was designed to help participants develop resilience skills and contribute to the reduction of stress, anxiety, and depression [ 26 ]. To assess the effectiveness of the intervention in terms of mental health (the presence of current depressive symptoms), general self-efficacy, chronic disease self-management self-efficacy as well as physical activity and nutrition self-efficacy, a section of the SEFAC questionnaire was used. The questionnaire was developed as part of the SEFAC project [ 27 ]. To assess the internal consistency, Cronbach’s alphas were calculated with acceptable values ranging from 0.70 to 0.95 [ 28 ]. To evaluate the presence of the presence of current depressive symptoms, the 8-Item Patient Health Questionnaire Depression Scale (PHQ-8) (Cronbach’s alpha 0.78) whose values are ranging from 0–24 and higher scores meaning higher depressive symptoms severity [ 29 ]. Self-efficacy was assessed with four questionnaires: General Self-Efficacy Scale (GSES) (Cronbach’s alpha 0.90), Self-Efficacy for Managing Chronic Diseases 6-item Scale (SEMCD) (Cronbach’s alpha 0.92), The Physical Exercise Self-Efficacy Scale (PESS) (Cronbach’s alpha 0.96) and The Nutrition Self-Efficacy Scale (NSES) (Cronbach’s alpha 0.96) [ 14 , 30 – 31 ]. Higher values represented higher levels of general, chronic disease self-management, physical activity, and nutrition self-efficacy. Besides the outcome measures, general socio-demographic characteristics were also obtained: age, sex, chronic diseases and conditions presence, marital status, household composition, educational level, and household income. Data was collected at two time points: T0 (baseline measurement) and T1 (measurement 6 months after the intervention ended). The collected data was statistically processed in IBM SPSS Statistics 28.0.0.0. (IBM Corporation, Armonk, NY, USA). All participants that filled out the baseline and the follow-up questionnaire were included in the final analysis. Before applying the right statistical test for quantitative data, the Kolmogorov-Smirnov test was performed. Depending on the results, the paired t-test or Wilcoxon signed-rank test was done for outcome measures. The analysis of categorical dichotomous data was performed with the paired McNemar test. To analyse the effect size of the measured health outcome, Cohen’s d was also computed. The level of statistical significance was α = 0.05. This research has been conducted in accordance with all applicable policies designed to ensure the proper conduct of the research and the safety of persons participating in this research, while respecting the principles of good clinical practice. The research respected fundamental ethical and bioethical principles - personal integrity (autonomy), justice, charity and innocence - in accordance with the Nuremberg Code and the latest revision of the Declaration of Helsinki of the World Medical Association, the Health Act of the Republic of Croatia (OG 158/08, 71/10, 139/10, 22/11, 84/11, 12/12, 35/12, 70/12, 82/13, 100/18 and 125/19), the Patients' Rights Act of the Republic of Croatia (OG 169/04, 37 / 08) and Regulation (EU) 2016/679 of the European Parliament and of the Council of 27. April 2016 on the protection of individuals regarding the processing of personal data and on the free movement of such data. The study was approved by the Ethics Committee of the University of Rijeka, Faculty of Medicine (Class: 003–08/20 − 01/91; Registration number: 2170-24-09-8-20-3) and by the Ethics Committee of the Health Centre of Primorje-Gorski Kotar County, Rijeka, Croatia (Registration number: 01–47/2-2-21). The study was retrospectively registered on 30 August 2018 under ISRCTN registry number ISRCTN11248135. Results In total, 257 participants were included in the study: 130 within the intervention group and 127 in the control group. General socio-demographic characteristics and baseline outcome measures for both study groups are shown in Table 1 . Table 1 General socio-demographic characteristics and baseline outcome measures of the intervention and control group Intervention group (N = 130) N (%) Control group (N = 127) N (%) p-value Age (y) 71.2 72.1 0.173 Sex Female 116 (89.2%) 83 (65.4%) < .001 Male 14 (10.8%) 44 (34.6%) Chronic diseases Heart failure 16 (12.3%) 17 (13.4%) 0.853 Hypertension 74 (56.9%) 71 (55.9%) 0.900 Type II diabetes 22 (16.9%) 26 (20.5%) 0.523 Marital status Single 16 (12.3%) 13 (10.2%) 0.008 Partnership 65 (50.0%) 92 (72.4%) Widow(er) 49 (37.7%) 22 (17.3%) Household composition Living alone 48 (36.9%) 22 (17.3%) < .001 Living with others 82 (63.1%) 105 (82.7%) Educational level Primary or less 24 (18.5%) 8 (6.3%) 0.494 Secondary 64 (49.2%) 84 (66.1%) Tertiary or higher 42 (32.3%) 35 (27.6%) Household income Decile 1 + 2 (< 239–345 €) 24 (18.5%) 10 (7.9%) 0.339 Decile 3 + 4 (346–597 €) 50 (38.5%) 55 (43.3%) Decile 5 + 6 (598–889 €) 26 (20.0%) 39 (30.7%) Decile 7 + 8 (890-1,287 €) 20 (15.4%) 19 (15.0%) Decile 9 + 10 (1,288 - >1,606 €) 10 (7.7%) 4 (3.1%) As shown in Table 1 ., the average age of participants who participated in the mindfulness-based intervention was 71.2 years and those who were part of the control group was 72.1 (p = 0.173). Regarding the presence of chronic non-communicable diseases, almost the same number of participants from both groups had heart failure, hypertension, and type II diabetes with no statistically significant differences present. The differences in education level and household income among the intervention and control participants were also non-significant (p = 0.494 and p = 0.339). For a clearer visualisation of the results, household income was divided into five deciles. On the other hand, the statistical significance of the difference in gender structure between these two groups was proven (p < .001). In the intervention group, almost 90% of participants were women, while in the control group that was 65.4%. The statistical difference was also present in the marital status of participants (p = 0.008). More than 80% participants within the control group lived with others (family, friends) as 36.9% (N = 48) of participants in the intervention group lived alone. The effectiveness of the intervention on mental health (the presence of depressive symptoms), general self-efficacy, chronic disease self-management self-efficacy as well as physical activity and nutrition self-efficacy is shown in Table 2 . Data are presented as means with standard deviation included within the brackets. All the assessed segments have significantly changed in the intervention group at 6-months follow-up. There is significant reduction of depression in the intervention group (p < .001) compared to control (p = 0.262). General self-efficacy, chronic disease self-management self-efficacy, physical activity self-efficacy and nutrition self-efficacy outcomes also significantly improved in the intervention group while in the control group the general self-efficacy was significantly reduced (p = 0.011). Table 2 Outcome measures before and after the seven-week mindfulness-based public health intervention Intervention group (T0) Intervention group (T1) Cohen's d 95% Confidence Interval of the Difference - Lower 95% Confidence Interval of the Difference - Upper p-value Control group (T0) Control group (T1) Cohen's d 95% Confidence Interval of the Difference - Lower 95% Confidence Interval of the Difference - Upper p-value N = 130 x̄ (SD) N = 127 x̄ (SD) Mental health (current depressive symptoms) PHQ-8 5.9 (3.0) 4.9 (2.9) 0.347 0.49 1.47 < .001 5.6 (3.4) 5.8 (3.3) -0.059 -0.68 0.34 0.262 Self-efficacy GSES 31.8 (4.8) 33.6 (5.3) -0.35 -2.66 -0.9 < .001 32.0 (4.9) 31.0 (4.9) 0,19 0.11 2.01 0.011 SEMCD 7.1 (0.1) 7.8 (0.1) -0.46 -0.92 -0.42 < .001 6.9 (0.2) 6.8 (0.1) 0,02 -0.26 0.33 0.803 PESES 13.8 (4.4) 14.7 (4.6) -0.18 -1.67 -0.04 0.040 12.2 (4.3) 12.0 (4.2) 0,05 -0.49 0.88 0.351 NSES 13.9 (4.2) 14.6 (4.0) -0.2 -1.39 -0.13 0.024 12.9 (4.3) 12.4 (3.8) 0.11 -0.27 1.33 0.217 N = number x̄ = mean SD = standard deviation PHQ-8 = 8-item Patient Health Questionnaire Depression Scale GSES = General Self-Efficacy Scale SEMCD = Self-Efficacy for Managing Chronic Diseases 6-item Scale PESES = Physical Exercise Self-Efficacy Scale NSES = Nutrition Self-Efficacy Scale Discussion As the world's population ages, effective interventions to maintain and improve mental health and self-efficacy in older people are becoming increasingly important [ 32 ]. Mental health issues such as depression and anxiety are common in older people and significantly affect their quality of life [ 33 ]. In addition, age-related changes in physiological and psychological functioning often lead to increased vulnerability to stress, exacerbating existing health conditions [ 15 ]. Self-efficacy, i.e. the belief in one's own ability to perform certain tasks or behaviours, plays a crucial role in successful ageing as it influences health behaviours, medication adherence and general well-being [ 34 ]. In addition, prevention and early intervention strategies are also crucial for promoting mental health and well-being in older people. These strategies include fostering social connections, encouraging physical activity and cognitive stimulation, and providing access to mental health services tailored to the specific needs of this population. In this context, mindfulness-based interventions offer a promising approach for treating older people mental health issues and promoting their overall well-being. Mindfulness involves non-judgemental awareness of the present moment and has been associated with improved psychological well-being and adaptive coping strategies [ 35 ]. The results of our study contribute to the growing body of evidence on the effectiveness of mindfulness-based interventions to improve mental health and self-efficacy in older people. Our results indicate significant improvements in mental health and self-efficacy in the intervention group compared to the control group. As shown in the previous sections, five measurement scales were used, one for mental health and four for self-efficacy, and the intervention group performed better on each of these scales after the intervention period. The control group, on the other hand, performed slightly worse in each individual category after the intervention period. The results of our study show that older people in the intervention group experienced a significant decrease in depressive symptoms (from 5.9 to 4.9; p < .001), while in the control group depressive symptoms were slightly higher at follow-up (from 5.6 to 5.8; p = 0.262). This finding is consistent with previous research demonstrating the effectiveness of mindfulness-based interventions in reducing depressive symptoms in at-risk populations, which undoubtedly include the older population [ 36 ]. A retrospective analysis by Young and Baime (2010) also supported the positive effects of mindfulness on mental health in older people, reporting lower rates of anxiety and depression [ 37 ]. Mindfulness-based interventions have been shown to improve emotion regulation and increase positive affect, thereby contributing to an overall improvement in mental health [ 38 ]. In addition, mindfulness-based interventions have been shown to not only reduce depressive symptoms but also improve cognitive abilities in older people, such as attention, memory and executive functions [ 39 ]. According to a recent study by Fam et al. (2020) in an older population with mild cognitive impairment, mindfulness-based interventions also improved cognitive performance [ 40 ]. A systematic review by Kayser et al. (2023) has shown that mindfulness-based interventions in older people with various chronic conditions and diseases such as chronic pain, stroke, cancer, type II diabetes, chronic obstructive pulmonary disease and insomnia were able to reduce levels of depression, anxiety and pain while improving psychological well-being [ 41 ]. Our study found that participants in the intervention group achieved higher levels of general self-efficacy (p < .001), chronic disease management self-efficacy (p < .001), physical activity self-efficacy (p = 0.040) and nutrition self-efficacy (p = 0.024) after the intervention. Self-efficacy of participants in the control group was the same before and after the intervention, apart from general self-efficacy, which was significantly lower in this group at follow-up (p = 0.011). These results in the intervention participants are in line with previous studies demonstrating the positive influence of mindfulness on self-efficacy in different population groups [ 42 – 44 ]. In addition to self-esteem, self-efficacy is another key element of positive psychology that encourages a person to perform a particular task or behaviour successfully [ 42 ]. In this context, a previously published randomised clinical trial by Morone et al. (2009) reported that a mindfulness intervention increased self-efficacy in the management of chronic low back pain in older people and in the self-management of cardiovascular disease [ 45 – 47 ]. In addition, a study by Tsai et al. (2023) showed that a mindfulness-based physical activity intervention in older people led to an increase in self-efficacy in preventing falls and a reduction in fear of falling, which had a positive impact on physical and physiological health [ 48 ]. As already mentioned, the intervention phase of our study was conducted during the COVID-19 pandemic. This period was characterised by various epidemiological measures, including government-imposed lockdowns, and had a strong impact on the lives of the entire population. Among other restrictions, people were forced to stay indoors, which affected the possibility of direct social contact and reduced opportunities for physical activity. Previous studies have shown significant differences in self-efficacy and symptoms of depression between physically active and inactive older people [ 49 ] and a direct correlation between self-efficacy and psychological well-being [ 50 ]. In addition to a variety of the restrictive measures that were in place, people were very concerned about their health. Considering the results in the intervention group, it is reasonable to assume that this mindfulness-based community intervention was successful because it provided participants with a sufficient level of psychological support to overcome this stressful and very challenging time, especially for their mental health and general well-being. This statement is further supported by the results of the control group, in which a significantly lower level of general self-efficacy was found in the follow-up measurement. The fact that scores increased in every single category in the intervention group further supports the hypothesis that a mindfulness-based approach can be successful in managing stress levels and overall mental health. In addition to the mental health benefits of the intervention, it has also been shown to be an effective tool for improving the health of participants with chronic diseases by encouraging them to self-manage and self-monitor their disease and/or condition, empowering them and increasing their self-efficacy, as well as adopting a healthier lifestyle in relation to modifiable factors to achieve better health outcomes. Apart from the direct health benefits, this programme can also have a sustainable impact and save costs from the perspective of citizens at risk for or suffering from serious chronic diseases such as cardiovascular disease and type II diabetes. In addition, such an approach can also be beneficial for the healthcare system in general, as it can help to save the system’s resources by reducing costs and utilising services more effectively. These and similar studies could also provide evidence for health policy makers to propose reforms for more effective and efficient models of chronic disease prevention and management. Finally, there are also some limitations of the present study that need to be addressed. The limitations of this study apply not only to this study, but also to all other similar studies. Firstly, people are willing to participate in a study of this nature that aims to change their lifestyle in a healthier direction. Generalisation to the whole population is therefore uncertain. Another challenge that should be addressed is more directly related to the results of this study. While the intervention group and the control group are similar in size (the difference is less than 3%), the differences in gender structure between the two groups were significant. Although both groups included predominantly female participants, the number of men in the intervention group was almost negligible. These differences can be explained by several possible factors that could have an influence on the gender structure. First, women might be more interested in a healthier lifestyle, whereas men are more prone to risky behaviour and general neglect of their health [ 51 , 52 ]. Furthermore, it should be considered that the study was conducted in Croatia, where some gender-specific behaviours might be more pronounced due to more traditional gender roles and behaviours. Another fact that should be mentioned is that there was a statistically significant difference between the intervention and control groups in terms of self-efficacy levels for physical activity at baseline, and to a lesser extent in the baseline measurement of nutrition self-efficacy. This can be explained by the fact that the participants in the intervention group are more interested in leading a healthier lifestyle and that these two aspects are most directly and easily influenced by daily lifestyle choices and a growing mindset. Mindfulness-based community intervention that combines the theoretical framework of salutogenesis, the person-centred approach, positive psychology, behaviour change theory based on the Transtheoretical Model, mindfulness, the GROW coaching model and two evidence-based programmes: The Chronic Disease Self-Management Programme (CDSMP) and the Mindfulness-based Living Programme was shown to have a significant positive impact on all aspects encompassed by this study (mental health and four different types of self-efficacy). The positive impact on mental health was particularly notable given that a large part of the study was conducted at the height of the COVID-19 pandemic. This shows that the proposed approach can be effective even under very unfavourable conditions. The results of the study suggest that the approach can have a direct benefit on the health of older population and that it can be useful in the prevention and/or management of chronic diseases as well as in the development of various self-management strategies. Approaches such as this could lead to a reduction in healthcare costs and therefore be beneficial not only for older people, but also for the population in general and for a healthcare system. Overall, mindfulness-based interventions have the potential for further study and the search for valid ways to manage the health of an increasingly ageing population. Declarations Competing interests : The author(s) declare no competing interests. Ethical approval : The study has received ethical approvals from the Ethics Committee of University of Rijeka, Faculty of Medicine (class: 003–08/20 − 01/91; registry number: 2170-24-09-8-20-3) on and as well as from the Ethics Committee from the Community Health Centre of Primorje-Gorski Kotar County, Rijeka, Croatia (registry number: 01–47/2-2-21). The research also ensured personal integrity, justice, charity and innocence of participants, in accordance with the Nuremberg Code and the latest revision of the Declaration of Helsinki, the Health Care Act of the Republic of Croatia (OG 158/08, 71/10, 139/10, 22/11, 84/11, 12/12, 35/12, 70/12, 82/13, 100/18 and 125/19), the Patients' Rights Act of the Republic of Croatia (OG 169/04, 37/08) and Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of individuals with regard to the processing of personal data and on the free movement of such data. Informed consent : Informed consent was obtained from all participants included in this study, including their legal guardians where applicable. Funding: Part of this study was carried out with the financial support from the Third Health Program of the European Union (2014–2020), throughout the SEFAC project [grant number 738202]. The study does not necessarily reflect the Commission’s views and in no way anticipates the Commission’s future policy in this area. Part of this research was funded with the financial support of the University of Rijeka, through project “Improvement of the control of polypharmacy and adherence to the prescribed therapy of chronic diseases by using information-communication technologies” (project number uniri-biomed-18-227). The work of doctoral student Denis Juraga has been supported in part by the “Young researchers' career development project – training of doctoral students” of the Croatian Science Foundation. Author Contribution Conceptualization: DJ, VV, TR and MMG; Methodology: DJ and DR; Project administration: LB, MK and HR; Formal analysis: DJ and HR; Investigation: DJ, VV, MK and MMG; Resources: LB and MK; Data curation: DJ, DR and VV; Writing - original draft preparation: DJ and HR; Writing - review and editing: MMG and VV; Visualisation: DJ and DR; Supervision: TR and VV. All authors have read and approved to the published version of the manuscript. All authors have agreed both to be personally accountable for the author's own contributions and ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. Data Availability The data presented in this study are available on request from the corresponding author. 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Mindfulness Association [Internet]. Edinburgh: Mindfulness Based Living Course (MBLC); c2008-2020 [cited 2024 May 17]. Available from: https://www.mindfulnessassociation.net/mindfulness-courses/8-week-mblc/ Juraga, D. et al . Comparison of conventional (face-to-face) and online approach in mindfulness-based chronic disease self-management interventions for older adults. J. Public. Health. Res. 11, 2779. https://doi.org/10.4081/jphr.2022.2779 (2022). Zhang, X. et al . Evaluation design of the Social Engagement Framework for Addressing the Chronic-disease-challenge (SEFAC): A mindfulness-based intervention to promote the self-management of chronic conditions and a healthy lifestyle. BMC Public Health. 19, 664. https://doi.org/10.1186/s12889-019-6979-7 (2019). Tavakol, M. & Dennick, R. Making sense of Cronbach's alpha. Int. J. Med. Educ. 2, 53–55. https://doi.org/10.5116/ijme.4dfb.8dfd (2011). Kroenke, K. et al . The PHQ-8 as a measure of current depression in the general population. J. Affect. Disord. 114, 163–173. https://doi.org/10.1016/j.jad.2008.06.026 (2009). Hu, H., Li, G., & Arao, T. Validation of a Chinese version of the self-efficacy for managing chronic disease 6-item scale in patients with hypertension in primary care. ISRN Public Health. 1–6. https://doi.org/10.1155/2013/298986 (2013). Schwarzer, R., & Renner, B. Health-Specific Self-Efficacy Scales (2009). Retrieved May 21, 2024, from https://userpage.fu-berlin.de/health/healself.pdf United Nations, Department of Economic and Social Affairs, Population Division. World Population Ageing 2019 (2020). New York: United Nations. Retrieved May 21, 2024, from https://www.un.org/en/development/desa/population/publications/pdf/ageing/WorldPopulationAgeing2019-Report.pdf Ribeiro, O. et al . Anxiety, depression and quality of life in older adults: Trajectories of influence across age. Int. J. Environ. Res. Public. Health. 17, 9039. https://doi.org/10.3390/ijerph17239039 (2020). Alavijeh, M. S., Zandiyeh, Z. & Moeini, M. The effect of self-care self-efficacy program on life satisfaction of the Iranian elderly. J. Educ. Health Promot. 10, 167. https://doi.org/10.4103/jehp.jehp_928_20 (2021). Brown, K. W., Ryan, R. M. & Creswell, J. D. Mindfulness: theoretical foundations and evidence for its salutary effects. Psychol. Inq. 18, 211–237. https://doi.org/10.1080/10478400701598298 (2007). Creswell, J. D. Mindfulness interventions. Annu. Rev. Psychol. 68, 491–516. https://doi.org/10.1146/annurev-psych-042716-051139 (2017). Young, L. & Baime, M. J. Mindfulness-based stress reduction: Effect on emotional distress in older adults. Complement. Health Pract. Rev. 15, 59–64. https://doi.org/10.1177/1533210110387687 (2010). Guendelman, S., Medeiros, S. & Rampes, H. Mindfulness and emotion regulation: Insights from neurobiological, psychological, and clinical studies. Front. Psychol. 8, 220. https://doi.org/10.3389/fpsyg.2017.00220 (2017). Marciniak, R. et al . Effect of meditation on cognitive functions in context of aging and neurodegenerative diseases. Front. Behav. Neurosci. 8, 17. https://doi.org/10.3389/fnbeh.2014.00017 (2014). Fam, J. et al . Mindfulness practice alters brain connectivity in community-living elders with mild cognitive impairment. Psychiat. Clin. Neuros. 74, 257–262. https://doi.org/10.1111/pcn.12972 (2020). Kayser, J., Hu, R. X., Rosenscruggs, D., Li, L. & Xiang, X. A systematic review of the impact of select mindfulness interventions on psychological outcomes among older adults with chronic health conditions. Clin. Gerontol. 46, 302–314. https://doi.org/10.1080/07317115.2022.2076636 (2023). Chandna, S., Sharma, P. & Moosath, H. The mindful self: exploring mindfulness in relation with self-esteem and self-efficacy in Indian population. Psychol. Stud. 67, 261–272. https://doi.org/10.1007/s12646-021-00636-5 (2022). Firth, A. M., Cavallini, I., Sütterlin, S. & Lugo, R. G. Mindfulness and self-efficacy in pain perception, stress and academic performance. The influence of mindfulness on cognitive processes. Psychol. Res. Behav. Manag. 12, 565–574. https://doi.org/10.2147/PRBM.S206666 (2019). Bayır, B. & Aylaz, R. The effect of mindfulness-based education given to individuals with substance-use disorder according to self-efficacy theory on self-efficacy perception. Appl. Nurs. Res. 57, 151354. https://doi.org/10.1016/j.apnr.2020.151354 (2021). Morone, N. E., Rollman, B. L., Moore, C. G., Li, Q. & Weiner, D. K. A mind-body program for older adults with chronic low back pain: results of a pilot study. Pain. Med. 10, 1395–1407. https://doi.org/10.1111/j.1526-4637.2009.00746.x (2009). Korenhof, S. A. et al . Evaluation of an intervention to promote self-management regarding cardiovascular disease: The Social Engagement Framework for Addressing the Chronic-Disease-Challenge (SEFAC). Int. J. Environ. Res. Public. Health. 19, 13145. https://doi.org/10.3390/ijerph192013145 (2022). Tabernero, C. et al . Effectiveness of mindfulness and positive strengthening mHealth interventions for the promotion of subjective emotional wellbeing and management of self-efficacy for chronic cardiac diseases. J. Pers. Med. 12, 1953. https://doi.org/10.3390/jpm12121953 (2022). Tsai, C. C. et al . The efficacy of a mindfulness-based exercise program in older residents of a long-term care facility in Taiwan. Geriatr. Nurs. 50, 227–233. https://doi.org/10.1016/j.gerinurse.2023.01.021 (2023). Camp, N., Fernandes Ramos, A. C., Hunter, K., Boat, R. & Magistro, D. Differences in self-control, self-efficacy and depressive symptoms between active and inactive middle-aged and older adults after 1 year of COVID restrictions. Aging Ment. Health. 27, 483–488. https://doi.org/10.1080/13607863.2022.2046691 (2023). Mumtaz, A., Manzoor, F., Jiang, S. & Anisur Rahaman, M. COVID-19 and mental health: A study of stress, resilience, and depression among the older population in Pakistan. Healthcare. 9, 424. https://doi.org/10.3390/healthcare9040424 (2021). Wang, Y., Hunt, K., Nazareth, I., Freemantle, N., & Petersen, I. Do men consult less than women? An analysis of routinely collected UK general practice data. BMJ Open. 3, e003320. https://doi.org/10.1136/bmjopen-2013-003320 (2013). Courtenay, W. H. Constructions of masculinity and their influence on men's well-being: A theory of gender and health. Soc Sci Med. 50, 1385–1401. https://doi.org/10.1016/s0277-9536(99)00390-1 (2000). Additional Declarations No competing interests reported. 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. 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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-4528431","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":326641313,"identity":"93bfb307-948e-4a18-8a97-a35d0ea7ca5b","order_by":0,"name":"Denis 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06:59:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":517419,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4528431/v1/76a4d066-7904-4307-9847-04611d461630.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Improving mental health and self-efficacy in older people through a mindfulness-based community intervention","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAgeing is diverse and complex and includes a multitude of biological, psychological and social changes that become a part of the experience of growing older [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Examples include vulnerability to stress, loss of self-efficacy and loss of mental health (all often exacerbated by age-related problems such as physical health issues and cognitive deterioration and social isolation) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. With the growing age structure of the world\u0026rsquo;s population, attention to mental wellbeing for older people is becoming a vital consideration for the delivery of evidence-based mental health intervention into the future considering well-being and quality of life of older people.\u003c/p\u003e \u003cp\u003eMental health is an essential component of overall health. It encompasses emotional, psychological and social well-being and enables the individual to successfully cope with the complexities and challenges of life [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. A healthy mind is characterised by maintaining fulfilling relationships, coping with stress, feeling satisfied and coping with change or difficulties [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Maintaining mental health is particularly important for older individuals who are struggling with age-related issues such as cognitive decline, physical difficulties and social isolation [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Numerous factors, including biological aspects such as genetic predispositions and changes in brain chemistry, influence the onset and progression of mental health problems in older people [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In addition, psychological factors such as personality traits and coping mechanisms play an important role in how people respond to stress and adversity [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The mental health of older people is also influenced by social variables, including social support, financial resources and cultural aspects [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Understanding and managing these various factors that influence the mental health of older people is becoming increasingly important as the world's population ages. Older people often suffer from mental health problems such as depression and anxiety. According to research data, 20% of people over the age of 60 suffer from mental health problems [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. These problems can lead to a higher level of disability, a poorer standard of living and an increase in healthcare costs [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In addition, older people's mental health problems are often not properly recognised and treated, exacerbating the impact on individuals and society as a whole [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition to mental health, chronic diseases as a physical component of health are the main cause of disability and mortality in older people [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Most older individuals suffer from multiple chronic conditions that can affect their quality of life. In addition, the increasing prevalence of chronic conditions is linked to physical functioning and a significant increase in healthcare costs. To cope with this burden, older people can acquire new life skills to effectively self-manage their illnesses [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Self-efficacy is a psychological concept that refers to a person's confidence in their ability to perform a particular task or behaviour [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This important element influences motivation, persistence and resilience and is associated with several positive outcomes, including better stress management, better mental health and higher life satisfaction [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Fostering a strong sense of self-efficacy can help older people overcome the obstacles of ageing, maintain their independence, adapt to changing roles and responsibilities and maintain a good quality of life [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMindfulness as a state of mind characterised by non-judgemental observation of the present moment [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] has attracted much attention for its potential to promote mental health and resilience. Rooted in ancient Buddhist philosophy, mindfulness practices such as meditation, body scans, and mindful exercises like yoga aim to enhance present-moment awareness, offering psychological and physical benefits [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Studies consistently show that mindfulness practises improve psychological well-being by reducing symptoms of depression, anxiety and stress [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] while improving self-compassion, life satisfaction and emotional regulation [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In terms of stress reduction, mindfulness promotes adaptive coping mechanisms such as problem solving, emotion control and cognitive reorganisation, which helps people to better manage stress and respond to stressors [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In addition, mindfulness practises are also associated with increased self-efficacy by promoting greater self-awareness, self-compassion and a more accurate understanding of one's own abilities and limitations [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe aim of the study was to investigate the effectiveness of a seven-week mindfulness-based community intervention on mental health and self-efficacy in older people. This seven-week mindfulness-based workshop programme combines the theoretical framework of salutogenesis, the person-centred approach, positive psychology, behaviour change theory based on the Transtheoretical Model, mindfulness, the GROW coaching model (Goal, Reality, Options, and Will model) and two already known evidence-based programmes: The Chronic Disease Self-Management Programme (CDSMP) and the Mindfulness-based Living Programme [\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eWhile conducting the study, the study participants were divided into two groups. The first consisted of the participants who took part in a mindfulness-based intervention and the second was the control group. The participants were residents of the city of Rijeka and the wider urban area. Inclusion in each group was based on the geographical location of the participants and their GPs/community patronage nurses. The first patients to visit their GP or community patronage nurses and considering the inclusion and exclusion criteria, the research has been presented after which they decided whether they wanted to participate in the study. In line with the research methodology, participants were given the option to take part in either the intervention or the control group.\u003c/p\u003e \u003cp\u003eInclusion criteria for participants were persons of both sexes, older than 65 years, presence of a chronic disease such as cardiovascular diseases/condition (heart failure, hypertension) and/or diabetes type II, residing in the city of Rijeka and the wider urban area, and able to participate in the study for a period of 6 months. On the other hand, the exclusion criteria were the following: persons who do not have a permanent residence in the city of Rijeka and the wider urban area, persons who were not able to participate in the study for 6 months (persons planning to travel for a longer period of time or terminally ill patients), persons who are without a home, persons suffering from a mental illness according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV), persons with cognitive impairments and addicts of alcohol and other addictive substances.\u003c/p\u003e \u003cp\u003eThis pretest-post-test non-equivalent groups design research study was conducted from 1 October 2019 to 15 August 2022, during which time the intervention participants attended the seven-week workshop programme. The workshops were organised so that participants were divided into smaller groups of up to 10 people and lasted 2 hours while respecting all epidemiological measures which were active during the Coronavirus disease 2019 (COVID-19) pandemic. The aim of the seven-week workshop programme, led by trained workshop facilitators, was to induce behaviour change in the participants, make them aware of their habits and lifestyle, and reduce the risk factors that are modifiable: obesity, unhealthy diet, physical inactivity, harmful alcohol consumption, tobacco use, and learning new skills to improve self-efficacy, self-esteem and the ability to self-manage their health. In addition, the programme of workshops was designed to help participants develop resilience skills and contribute to the reduction of stress, anxiety, and depression [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo assess the effectiveness of the intervention in terms of mental health (the presence of current depressive symptoms), general self-efficacy, chronic disease self-management self-efficacy as well as physical activity and nutrition self-efficacy, a section of the SEFAC questionnaire was used. The questionnaire was developed as part of the SEFAC project [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. To assess the internal consistency, Cronbach\u0026rsquo;s alphas were calculated with acceptable values ranging from 0.70 to 0.95 [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. To evaluate the presence of the presence of current depressive symptoms, the 8-Item Patient Health Questionnaire Depression Scale (PHQ-8) (Cronbach\u0026rsquo;s alpha 0.78) whose values are ranging from 0\u0026ndash;24 and higher scores meaning higher depressive symptoms severity [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Self-efficacy was assessed with four questionnaires: General Self-Efficacy Scale (GSES) (Cronbach\u0026rsquo;s alpha 0.90), Self-Efficacy for Managing Chronic Diseases 6-item Scale (SEMCD) (Cronbach\u0026rsquo;s alpha 0.92), The Physical Exercise Self-Efficacy Scale (PESS) (Cronbach\u0026rsquo;s alpha 0.96) and The Nutrition Self-Efficacy Scale (NSES) (Cronbach\u0026rsquo;s alpha 0.96) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Higher values represented higher levels of general, chronic disease self-management, physical activity, and nutrition self-efficacy. Besides the outcome measures, general socio-demographic characteristics were also obtained: age, sex, chronic diseases and conditions presence, marital status, household composition, educational level, and household income.\u003c/p\u003e \u003cp\u003eData was collected at two time points: T0 (baseline measurement) and T1 (measurement 6 months after the intervention ended). The collected data was statistically processed in IBM SPSS Statistics 28.0.0.0. (IBM Corporation, Armonk, NY, USA). All participants that filled out the baseline and the follow-up questionnaire were included in the final analysis. Before applying the right statistical test for quantitative data, the Kolmogorov-Smirnov test was performed. Depending on the results, the paired t-test or Wilcoxon signed-rank test was done for outcome measures. The analysis of categorical dichotomous data was performed with the paired McNemar test. To analyse the effect size of the measured health outcome, Cohen\u0026rsquo;s d was also computed. The level of statistical significance was α\u0026thinsp;=\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003eThis research has been conducted in accordance with all applicable policies designed to ensure the proper conduct of the research and the safety of persons participating in this research, while respecting the principles of good clinical practice. The research respected fundamental ethical and bioethical principles - personal integrity (autonomy), justice, charity and innocence - in accordance with the Nuremberg Code and the latest revision of the Declaration of Helsinki of the World Medical Association, the Health Act of the Republic of Croatia (OG 158/08, 71/10, 139/10, 22/11, 84/11, 12/12, 35/12, 70/12, 82/13, 100/18 and 125/19), the Patients' Rights Act of the Republic of Croatia (OG 169/04, 37 / 08) and Regulation (EU) 2016/679 of the European Parliament and of the Council of 27. April 2016 on the protection of individuals regarding the processing of personal data and on the free movement of such data.\u003c/p\u003e \u003cp\u003e The study was approved by the Ethics Committee of the University of Rijeka, Faculty of Medicine (Class: 003\u0026ndash;08/20\u0026thinsp;\u0026minus;\u0026thinsp;01/91; Registration number: 2170-24-09-8-20-3) and by the Ethics Committee of the Health Centre of Primorje-Gorski Kotar County, Rijeka, Croatia (Registration number: 01\u0026ndash;47/2-2-21).\u003c/p\u003e \u003cp\u003eThe study was retrospectively registered on 30 August 2018 under ISRCTN registry number ISRCTN11248135.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn total, 257 participants were included in the study: 130 within the intervention group and 127 in the control group. General socio-demographic characteristics and baseline outcome measures for both study groups are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGeneral socio-demographic characteristics and baseline outcome measures of the intervention and control group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention group (N\u0026thinsp;=\u0026thinsp;130)\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl group (N\u0026thinsp;=\u0026thinsp;127)\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (y)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.173\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e116 (89.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83 (65.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (10.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (34.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eChronic diseases\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeart failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (12.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (13.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.853\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74 (56.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71 (55.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.900\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType II diabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (16.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (20.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.523\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (12.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (10.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e0.008\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePartnership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92 (72.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidow(er)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49 (37.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (17.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eHousehold composition\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiving alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (36.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (17.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiving with others\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82 (63.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e105 (82.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eEducational level\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary or less\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (18.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (6.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.494\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64 (49.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84 (66.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTertiary or higher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (32.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (27.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eHousehold income\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecile 1\u0026thinsp;+\u0026thinsp;2 (\u0026lt;\u0026thinsp;239\u0026ndash;345 \u0026euro;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (18.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (7.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.339\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecile 3\u0026thinsp;+\u0026thinsp;4 (346\u0026ndash;597 \u0026euro;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (38.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (43.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecile 5\u0026thinsp;+\u0026thinsp;6 (598\u0026ndash;889 \u0026euro;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (20.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (30.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecile 7\u0026thinsp;+\u0026thinsp;8 (890-1,287 \u0026euro;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (15.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (15.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecile 9\u0026thinsp;+\u0026thinsp;10 (1,288 - \u0026gt;1,606 \u0026euro;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (3.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e., the average age of participants who participated in the mindfulness-based intervention was 71.2 years and those who were part of the control group was 72.1 (p\u0026thinsp;=\u0026thinsp;0.173). Regarding the presence of chronic non-communicable diseases, almost the same number of participants from both groups had heart failure, hypertension, and type II diabetes with no statistically significant differences present. The differences in education level and household income among the intervention and control participants were also non-significant (p\u0026thinsp;=\u0026thinsp;0.494 and p\u0026thinsp;=\u0026thinsp;0.339). For a clearer visualisation of the results, household income was divided into five deciles. On the other hand, the statistical significance of the difference in gender structure between these two groups was proven (p\u0026thinsp;\u0026lt;\u0026thinsp;.001). In the intervention group, almost 90% of participants were women, while in the control group that was 65.4%. The statistical difference was also present in the marital status of participants (p\u0026thinsp;=\u0026thinsp;0.008). More than 80% participants within the control group lived with others (family, friends) as 36.9% (N\u0026thinsp;=\u0026thinsp;48) of participants in the intervention group lived alone.\u003c/p\u003e \u003cp\u003eThe effectiveness of the intervention on mental health (the presence of depressive symptoms), general self-efficacy, chronic disease self-management self-efficacy as well as physical activity and nutrition self-efficacy is shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Data are presented as means with standard deviation included within the brackets. All the assessed segments have significantly changed in the intervention group at 6-months follow-up. There is significant reduction of depression in the intervention group (p\u0026thinsp;\u0026lt;\u0026thinsp;.001) compared to control (p\u0026thinsp;=\u0026thinsp;0.262). General self-efficacy, chronic disease self-management self-efficacy, physical activity self-efficacy and nutrition self-efficacy outcomes also significantly improved in the intervention group while in the control group the general self-efficacy was significantly reduced (p\u0026thinsp;=\u0026thinsp;0.011).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOutcome measures before and after the seven-week mindfulness-based public health intervention\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"13\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention group (T0)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntervention group (T1)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCohen's d\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e95% Confidence Interval of the Difference - Lower\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e95% Confidence Interval of the Difference - Upper\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eControl group (T0)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eControl group (T1)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCohen's d\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e95% Confidence Interval of the Difference - Lower\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e95% Confidence Interval of the Difference - Upper\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;130\u003c/p\u003e \u003cp\u003ex̄ (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;127\u003c/p\u003e \u003cp\u003ex̄ (SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"13\" nameend=\"c13\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMental health\u003c/b\u003e (current depressive symptoms)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePHQ-8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.9 (3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.9 (2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.347\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5.6 (3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5.8 (3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-0.059\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.262\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"13\" nameend=\"c13\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSelf-efficacy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGSES\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31.8 (4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.6 (5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-2.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e32.0 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e31.0 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0,19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e2.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u003cb\u003e0.011\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSEMCD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.1 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.8 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e6.9 (0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6.8 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0,02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.803\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePESES\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.8 (4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.7 (4.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.040\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e12.2 (4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e12.0 (4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0,05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.351\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNSES\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.9 (4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.6 (4.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.024\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e12.9 (4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e12.4 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e-0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e1.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e0.217\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;number\u003c/p\u003e \u003cp\u003ex̄ = mean\u003c/p\u003e \u003cp\u003eSD\u0026thinsp;=\u0026thinsp;standard deviation\u003c/p\u003e \u003cp\u003ePHQ-8\u0026thinsp;=\u0026thinsp;8-item Patient Health Questionnaire Depression Scale\u003c/p\u003e \u003cp\u003eGSES\u0026thinsp;=\u0026thinsp;General Self-Efficacy Scale\u003c/p\u003e \u003cp\u003eSEMCD\u0026thinsp;=\u0026thinsp;Self-Efficacy for Managing Chronic Diseases 6-item Scale\u003c/p\u003e \u003cp\u003ePESES\u0026thinsp;=\u0026thinsp;Physical Exercise Self-Efficacy Scale\u003c/p\u003e \u003cp\u003eNSES\u0026thinsp;=\u0026thinsp;Nutrition Self-Efficacy Scale\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAs the world's population ages, effective interventions to maintain and improve mental health and self-efficacy in older people are becoming increasingly important [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Mental health issues such as depression and anxiety are common in older people and significantly affect their quality of life [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In addition, age-related changes in physiological and psychological functioning often lead to increased vulnerability to stress, exacerbating existing health conditions [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Self-efficacy, i.e. the belief in one's own ability to perform certain tasks or behaviours, plays a crucial role in successful ageing as it influences health behaviours, medication adherence and general well-being [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. In addition, prevention and early intervention strategies are also crucial for promoting mental health and well-being in older people. These strategies include fostering social connections, encouraging physical activity and cognitive stimulation, and providing access to mental health services tailored to the specific needs of this population. In this context, mindfulness-based interventions offer a promising approach for treating older people mental health issues and promoting their overall well-being. Mindfulness involves non-judgemental awareness of the present moment and has been associated with improved psychological well-being and adaptive coping strategies [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The results of our study contribute to the growing body of evidence on the effectiveness of mindfulness-based interventions to improve mental health and self-efficacy in older people.\u003c/p\u003e \u003cp\u003eOur results indicate significant improvements in mental health and self-efficacy in the intervention group compared to the control group. As shown in the previous sections, five measurement scales were used, one for mental health and four for self-efficacy, and the intervention group performed better on each of these scales after the intervention period. The control group, on the other hand, performed slightly worse in each individual category after the intervention period. The results of our study show that older people in the intervention group experienced a significant decrease in depressive symptoms (from 5.9 to 4.9; p\u0026thinsp;\u0026lt;\u0026thinsp;.001), while in the control group depressive symptoms were slightly higher at follow-up (from 5.6 to 5.8; p\u0026thinsp;=\u0026thinsp;0.262). This finding is consistent with previous research demonstrating the effectiveness of mindfulness-based interventions in reducing depressive symptoms in at-risk populations, which undoubtedly include the older population [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. A retrospective analysis by Young and Baime (2010) also supported the positive effects of mindfulness on mental health in older people, reporting lower rates of anxiety and depression [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMindfulness-based interventions have been shown to improve emotion regulation and increase positive affect, thereby contributing to an overall improvement in mental health [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. In addition, mindfulness-based interventions have been shown to not only reduce depressive symptoms but also improve cognitive abilities in older people, such as attention, memory and executive functions [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. According to a recent study by Fam et al. (2020) in an older population with mild cognitive impairment, mindfulness-based interventions also improved cognitive performance [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. A systematic review by Kayser et al. (2023) has shown that mindfulness-based interventions in older people with various chronic conditions and diseases such as chronic pain, stroke, cancer, type II diabetes, chronic obstructive pulmonary disease and insomnia were able to reduce levels of depression, anxiety and pain while improving psychological well-being [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Our study found that participants in the intervention group achieved higher levels of general self-efficacy (p\u0026thinsp;\u0026lt;\u0026thinsp;.001), chronic disease management self-efficacy (p\u0026thinsp;\u0026lt;\u0026thinsp;.001), physical activity self-efficacy (p\u0026thinsp;=\u0026thinsp;0.040) and nutrition self-efficacy (p\u0026thinsp;=\u0026thinsp;0.024) after the intervention. Self-efficacy of participants in the control group was the same before and after the intervention, apart from general self-efficacy, which was significantly lower in this group at follow-up (p\u0026thinsp;=\u0026thinsp;0.011). These results in the intervention participants are in line with previous studies demonstrating the positive influence of mindfulness on self-efficacy in different population groups [\u003cspan additionalcitationids=\"CR43\" citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. In addition to self-esteem, self-efficacy is another key element of positive psychology that encourages a person to perform a particular task or behaviour successfully [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. In this context, a previously published randomised clinical trial by Morone et al. (2009) reported that a mindfulness intervention increased self-efficacy in the management of chronic low back pain in older people and in the self-management of cardiovascular disease [\u003cspan additionalcitationids=\"CR46\" citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. In addition, a study by Tsai et al. (2023) showed that a mindfulness-based physical activity intervention in older people led to an increase in self-efficacy in preventing falls and a reduction in fear of falling, which had a positive impact on physical and physiological health [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. As already mentioned, the intervention phase of our study was conducted during the COVID-19 pandemic. This period was characterised by various epidemiological measures, including government-imposed lockdowns, and had a strong impact on the lives of the entire population. Among other restrictions, people were forced to stay indoors, which affected the possibility of direct social contact and reduced opportunities for physical activity. Previous studies have shown significant differences in self-efficacy and symptoms of depression between physically active and inactive older people [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] and a direct correlation between self-efficacy and psychological well-being [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. In addition to a variety of the restrictive measures that were in place, people were very concerned about their health. Considering the results in the intervention group, it is reasonable to assume that this mindfulness-based community intervention was successful because it provided participants with a sufficient level of psychological support to overcome this stressful and very challenging time, especially for their mental health and general well-being. This statement is further supported by the results of the control group, in which a significantly lower level of general self-efficacy was found in the follow-up measurement. The fact that scores increased in every single category in the intervention group further supports the hypothesis that a mindfulness-based approach can be successful in managing stress levels and overall mental health. In addition to the mental health benefits of the intervention, it has also been shown to be an effective tool for improving the health of participants with chronic diseases by encouraging them to self-manage and self-monitor their disease and/or condition, empowering them and increasing their self-efficacy, as well as adopting a healthier lifestyle in relation to modifiable factors to achieve better health outcomes. Apart from the direct health benefits, this programme can also have a sustainable impact and save costs from the perspective of citizens at risk for or suffering from serious chronic diseases such as cardiovascular disease and type II diabetes. In addition, such an approach can also be beneficial for the healthcare system in general, as it can help to save the system\u0026rsquo;s resources by reducing costs and utilising services more effectively. These and similar studies could also provide evidence for health policy makers to propose reforms for more effective and efficient models of chronic disease prevention and management.\u003c/p\u003e \u003cp\u003eFinally, there are also some limitations of the present study that need to be addressed. The limitations of this study apply not only to this study, but also to all other similar studies. Firstly, people are willing to participate in a study of this nature that aims to change their lifestyle in a healthier direction. Generalisation to the whole population is therefore uncertain. Another challenge that should be addressed is more directly related to the results of this study. While the intervention group and the control group are similar in size (the difference is less than 3%), the differences in gender structure between the two groups were significant. Although both groups included predominantly female participants, the number of men in the intervention group was almost negligible. These differences can be explained by several possible factors that could have an influence on the gender structure. First, women might be more interested in a healthier lifestyle, whereas men are more prone to risky behaviour and general neglect of their health [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Furthermore, it should be considered that the study was conducted in Croatia, where some gender-specific behaviours might be more pronounced due to more traditional gender roles and behaviours. Another fact that should be mentioned is that there was a statistically significant difference between the intervention and control groups in terms of self-efficacy levels for physical activity at baseline, and to a lesser extent in the baseline measurement of nutrition self-efficacy. This can be explained by the fact that the participants in the intervention group are more interested in leading a healthier lifestyle and that these two aspects are most directly and easily influenced by daily lifestyle choices and a growing mindset.\u003c/p\u003e \u003cp\u003eMindfulness-based community intervention that combines the theoretical framework of salutogenesis, the person-centred approach, positive psychology, behaviour change theory based on the Transtheoretical Model, mindfulness, the GROW coaching model and two evidence-based programmes: The Chronic Disease Self-Management Programme (CDSMP) and the Mindfulness-based Living Programme was shown to have a significant positive impact on all aspects encompassed by this study (mental health and four different types of self-efficacy). The positive impact on mental health was particularly notable given that a large part of the study was conducted at the height of the COVID-19 pandemic. This shows that the proposed approach can be effective even under very unfavourable conditions.\u003c/p\u003e \u003cp\u003eThe results of the study suggest that the approach can have a direct benefit on the health of older population and that it can be useful in the prevention and/or management of chronic diseases as well as in the development of various self-management strategies. Approaches such as this could lead to a reduction in healthcare costs and therefore be beneficial not only for older people, but also for the population in general and for a healthcare system. Overall, mindfulness-based interventions have the potential for further study and the search for valid ways to manage the health of an increasingly ageing population.\u003c/p\u003e"},{"header":"Declarations","content":" \u003ch2\u003e \u003cb\u003eCompeting interests\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003eThe author(s) declare no competing interests.\u003c/p\u003e \u003ch2\u003e \u003cb\u003eEthical approval\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003e The study has received ethical approvals from the Ethics Committee of University of Rijeka, Faculty of Medicine (class: 003\u0026ndash;08/20\u0026thinsp;\u0026minus;\u0026thinsp;01/91; registry number: 2170-24-09-8-20-3) on and as well as from the Ethics Committee from the Community Health Centre of Primorje-Gorski Kotar County, Rijeka, Croatia (registry number: 01\u0026ndash;47/2-2-21). The research also ensured personal integrity, justice, charity and innocence of participants, in accordance with the Nuremberg Code and the latest revision of the Declaration of Helsinki, the Health Care Act of the Republic of Croatia (OG 158/08, 71/10, 139/10, 22/11, 84/11, 12/12, 35/12, 70/12, 82/13, 100/18 and 125/19), the Patients' Rights Act of the Republic of Croatia (OG 169/04, 37/08) and Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of individuals with regard to the processing of personal data and on the free movement of such data.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003e \u003cb\u003eInformed consent\u003c/b\u003e:\u003c/strong\u003e \u003cp\u003e Informed consent was obtained from all participants included in this study, including their legal guardians where applicable.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003ePart of this study was carried out with the financial support from the Third Health Program of the European Union (2014\u0026ndash;2020), throughout the SEFAC project [grant number 738202]. The study does not necessarily reflect the Commission\u0026rsquo;s views and in no way anticipates the Commission\u0026rsquo;s future policy in this area. Part of this research was funded with the financial support of the University of Rijeka, through project \u0026ldquo;Improvement of the control of polypharmacy and adherence to the prescribed therapy of chronic diseases by using information-communication technologies\u0026rdquo; (project number uniri-biomed-18-227). The work of doctoral student Denis Juraga has been supported in part by the \u0026ldquo;Young researchers' career development project \u0026ndash; training of doctoral students\u0026rdquo; of the Croatian Science Foundation.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualization: DJ, VV, TR and MMG; Methodology: DJ and DR; Project administration: LB, MK and HR; Formal analysis: DJ and HR; Investigation: DJ, VV, MK and MMG; Resources: LB and MK; Data curation: DJ, DR and VV; Writing - original draft preparation: DJ and HR; Writing - review and editing: MMG and VV; Visualisation: DJ and DR; Supervision: TR and VV. All authors have read and approved to the published version of the manuscript. All authors have agreed both to be personally accountable for the author's own contributions and ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data presented in this study are available on request from the corresponding author. The data are not publicly available due to privacy and personal data related to the Regulation (EU) 2016/679 of the European Parliament and of the Council of April 27, 2016, on the protection of individuals regarding the processing of personal data and on the free movement of such data\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. World report on ageing and health (2015). Geneva: World Health Organization. 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Soc Sci Med. 50, 1385\u0026ndash;1401. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/s0277-9536(99)00390-1\u003c/span\u003e\u003cspan address=\"10.1016/s0277-9536(99)00390-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2000).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","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":"mental health, self-management, self-efficacy, mindfulness, public health","lastPublishedDoi":"10.21203/rs.3.rs-4528431/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4528431/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Ageing is a process that involves biological, psychological, and social changes making older people more susceptible to decreased self-efficacy and deteriorating their mental health. With the global population ageing, there is a growing demand for interventions tailored to address their specific mental health problems and improve their overall well-being. This study aimed to assess the effectiveness of a mindfulness-based community intervention on mental health and self-efficacy in older individuals. The study involved 257 participants who were divided into an intervention and a control group. Assessments were conducted at the beginning and 6 months after its completion. The results revealed a significant reduction in depression within the intervention group (p \u003c.001). Furthermore, the intervention led to significant improvements in general self-efficacy, chronic disease self-management self-efficacy, physical activity and nutrition self-efficacy within the intervention group compared to the control group. Overall, the results demonstrate the effectiveness of mindfulness-based community interventions in improving mental health and self-efficacy in older people in community settings. The results of the present study showed that this programme resulted in immediate health benefits in terms of mental health and self-efficacy of older people, while giving a contribution to the development of effective strategies for chronic disease self-management.","manuscriptTitle":"Improving mental health and self-efficacy in older people through a mindfulness-based community intervention","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-15 09:55:26","doi":"10.21203/rs.3.rs-4528431/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":"de7b7044-e648-4ad2-889a-dd907219b899","owner":[],"postedDate":"July 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":34561867,"name":"Health sciences/Health care/Public health"},{"id":34561868,"name":"Health sciences/Health care/Quality of life"}],"tags":[],"updatedAt":"2024-09-09T06:51:10+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-15 09:55:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4528431","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4528431","identity":"rs-4528431","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}