A randomised active-controlled trial to examine the effects of an online mindfulness intervention on executive control, critical thinking and key thinking dispositions in a university student sample

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Noone and Hogan BMC Psychology (2018) 6:13 https://doi.org/10.1186/s40359-018-0226-3 RESEARCH ARTICLE Open Access A randomised active-controlled trial to examine the effects of an online mindfulness intervention on executive control, critical thinking and key thinking dispositions in a university student sample Chris Noone* and Michael J. Hogan Abstract Background: Arguments for including mindfulness instruction in higher education have included claims about the benefits of mindfulness practice for critical thinking. While there is theoretical support for this claim, empirical support is limited. The aim of this study was to test this claim by investigating the effects of an online mindfulness intervention on executive function, critical thinking skills and associated thinking dispositions. Method: Participants recruited from a university were randomly allocated, following screening, to either a mindfulness meditation group or a sham meditation group. Both the researchers and the participants were blind to group allocation. The intervention content for both groups was delivered through the Headspace online application, an application which provides guided meditations to users. Both groups were requested to complete 30 guided mindfulness meditation sessions across a 6 week period. Primary outcome measures assessed mindfulness, executive functioning, critical thinking, actively open-minded thinking and need for cognition. Secondary outcome measures assessed wellbeing, positive and negative affect, and real-world outcomes. Results: In a series of full-information maximum likelihood analyses, significant increases in mindfulness dispositions and critical thinking scores were observed in both the mindfulness meditation and sham meditation groups. However, no significant effects of group allocation were observed for either primary or secondary measures. Furthermore, mediation analyses testing the indirect effect of group allocation through executive functioning performance did not reveal a significant result and moderation analyses showed that the effect of the intervention did not depend on baseline levels of the key thinking dispositions, actively open-minded thinking and need for cognition. Conclusion: No evidence was found to suggest that engaging in guided mindfulness practice for 6 weeks using the online intervention method applied in this study improves critical thinking performance. While further research is warranted, claims regarding the benefits of mindfulness practice for critical thinking should be tempered in the meantime. Trial registration: The study was initially registered in the AEA Social Science Registry before the recruitment was initiated (RCT ID: AEARCTR-0000756; 14/11/2015) and retrospectively registered in the ISRCTN registry (RCT ID: ISRCTN16588423) in line with requirements for publishing the study protocol. * Correspondence: chris.noone@nuigalway.ie School of Psychology, National University of Ireland Galway, Newcastle Road, Galway, Ireland © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Noone and Hogan BMC Psychology (2018) 6:13 Background Mindfulness has been operationalised as a mental state involving two components: the self-regulation of attention so that thoughts, feelings and sensations are observed and attended to in the present-moment and an orientation to experience characterised by acceptance, non-judgment and non-reactivity [1]. It has been claimed that mindfulness should facilitate critical thinking in higher-education, based on early Buddhist conceptualisations of mindfulness as clarity of thought [2]. There is theoretical support and some empirical evidence for this claim, such as in a recent crosssectional study where evidence for inhibition mediating a positive relationship between dispositional mindfulness and critical thinking was demonstrated [3] but it remains an open question as to whether mindfulness practice enhances critical thinking or not (or even hinders it; [4]). It is important to test the veracity of claims regarding mindfulness and critical thinking in the most rigorous way available. To achieve this, a randomised controlled trial was conducted to compare the effects of mindfulness training on executive function and critical thinking to those of a closely matched active control condition. Common to most conceptualisations of critical thinking in psychology is the need to evaluate arguments and evidence without influence from one’s own prior belief and experience [5]. Critical thinking involves the effective use of the cognitive skills of analysis, evaluation, and inference, in a purposeful, reasoned and goal-directed manner [6]. Halpern’s [6] description of the higher-order thinking skills involved in critical thinking includes verbal reasoning, argument analysis, hypothesis testing, estimating likelihood and dealing with uncertainty, problem solving, and decision-making. In her definition of critical thinking, its function is the selection of thinking strategies which increase the probability of a desirable outcome [7]. Thus the defining features of critical thinking are not the characteristics of the thinking skills employed but the process of selecting and executing the appropriate thinking skill and the monitor and control of this thinking process [6, 8, 9]. The appropriate execution of these critical thinking skills depends on the presence of specific dispositions towards thinking with two in particular being the focus of much research – need for cognition and actively open-minded thinking [5, 10–12]. The application of critical thinking skills also depends on the thinker’s awareness that a particular thinking skill is required, that the ongoing execution of the skill is adequate, and the ability to monitor and exert control to change ongoing thinking processes [8, 9, 13, 14]. Performance on measures of critical thinking and tasks assessing heuristic and biased thinking has been positively associated with better real-world outcomes [15–24]. Page 2 of 18 The rationale for this study relies on previous studies suggesting positive effects of mindfulness on aspects of executive functioning [25, 26] and higherorder cognition [3, 27–30] and a specific type of default-interventionist dual-process theory (i.e. the three-stage dual-process model of analytic engagement) which can act as a framework to integrate research on the effects of mindfulness on executive function and the self-regulation of thinking and decision-making [31]. Dual-process theories of cognition posit that cognitive processes can be organised into two categories: type-1 processes and type-2 processes. Type-1 processes are those which are generally fast, automatic and do not require working memory. Current evidence suggest that they occur by default in response to stimuli (due to either innate or learned tendencies) and resulting models of cognition are referred to as default-interventionist accounts. Type-2 processes are generally slow and controlled. Their defining feature is the representation and comparison of hypothetical models of the world which requires working memory resources. When presented with a given stimulus or situation, different cognitive simulations of possible actions are compared to test their appropriateness, before acting according to the preferred response [32, 33]. In most situations (i.e. those where the processes have not been automatized through experience), all higher-order thinking skills such as problem-solving, decision-making and critical thinking, involve type-2 processes. Since Type-1 processes occur by default, they must be overridden to allow the engagement of Type-2 processes. The control processes which achieve this are referred to as executive functions and the process of inhibition is particularly important [5, 34–36]. Inhibition is the process by which prepotent responses and habitual behaviours are overridden, thus allowing for other responses [35]. In line with this theory, individual differences in executive functioning tend to account for a significant share of the variance in higher-order thinking skill [37, 38]. Furthermore, there is much experimental evidence to support this model [39–41]. This model provides a useful theoretical framework for the current study for two reasons. First, mindfulness practice has been shown to be associated with improvements in executive functioning [25, 42]. A cognitive model of mindfulness proposed by Teper and colleagues [43] outlines the mechanisms which may connect mindfulness practice to the intervention of executive functioning in the dual-process model described above. This model suggests that the present-moment attention or observation cultivated during mindfulness practice allows for the detection of affective cues which are typically not noticed. This allows negative affective cues which serve as triggers for selfregulation to be noticed. These negative affective cues Noone and Hogan BMC Psychology (2018) 6:13 carry information indicating that an individual’s current state is inconsistent with their goal state. The model also implies that a mindful orientation of acceptance or nonreactivity involves inhibiting automatic tendencies to elaborate upon affective cues. Crucially, conflict between default type-1 responses has been shown to produce negative affective cues which are thought to trigger type-2 processes [41, 44–46]. Taken together, these sets of findings imply that present-moment attention may facilitate the detection of negative affective cues produced by the conflict of type-1 responses. They also imply that nonreactivity may facilitate the inhibition of type-1 responses required for type-2 processing to intervene. Second, studies showing improvements in certain aspects of higherorder thinking generally explain their results by claiming that mindfulness practice has trained participants to inhibit automatic, or type-1, processing [27, 29, 47, 48]. Notably, a recent cross-sectional study focusing on individual differences in mindfulness, executive functioning and critical thinking supported this model by demonstrating evidence for skill in inhibition mediating a positive relationship between mindfulness and critical thinking [3]. Advances in technology are allowing the design of mindfulness interventions with more experimental control than previously possible [49]. The development of smartphone and web applications focused on the delivery of guided meditations in particular has made it easier to implement rigorous designs by facilitating the inclusion of objective measures of time spent meditating and by reducing the resources needed for running an intervention as well as the demands placed on the participants. Previous studies involving smartphone delivery of mindfulness interventions focused on workplace stress [50], wellbeing [49], depression [51] and compassion [52]. A recent metaanalysis showed that online mindfulness interventions tend to yield comparable results to traditional interventions focused on similar outcome variables such as stress, depression, anxiety and wellbeing, with effect sizes ranging from g = 0.22 to g = 0.51 [53]. These studies can also be considered more rigorous due to the standardisation of instruction across participants in the experimental group and the use of objective measures of adherence to the intervention (provided through the app) rather than selfreport [54]. However, these studies would have been strengthened further by the inclusion of more closely matched active-control materials as has been done in offline studies [55, 56]. The current study takes this approach by using the same interface, the Headspace application, to deliver sham intervention content which participants could reasonably believe is mindfulness training [57, 58]. The current study The central research question for this study was “does regular mindfulness meditation practice facilitate critical Page 3 of 18 thinking through the enhancement of executive function?” A secondary research question focused on whether regular mindfulness meditation practice enhance critical thinking dispositions. Thinking dispositions are key determinants of critical thinking which may interact with mindfulness practice [59]. In addressing these questions, this study employed a randomised controlled trial which compared a 6-week online mindfulness meditation intervention to a 6-week online sham meditation intervention, which acted as an active-control condition. For a list of the study hypotheses, see Table 1. Many universities and other institutions are introducing mindfulness programmes with the promise of improving thinking skills [60]. While there are theoretical and historical reasons supporting this view, it has not been adequately investigated and so this claim is premature. The contribution of this study lies in its rigorous approach to investigating this claim for the first time in the context of a randomised controlled trial (RCT). Methods Design This pre-registered study involved a two-arm randomised-controlled superiority trial with one intervention condition, guided mindfulness meditation, and one active-control condition, sham meditation. The design employed was a 2 (condition) × 2 (time) parallel-group design which is explanatory in nature. Baseline measurement took place immediately before randomisation and follow-up measurement took place 6 weeks after the beginning of the intervention. The content of both the intervention condition and the active-control condition was delivered via a smartphone/online application between baseline and followup. Manipulation checks were carried out to assess intervention acceptability, technology acceptance and meditation quality 2 weeks after baseline and 4 weeks after baseline. See Fig. 1 for a flowchart including the procedure. The protocol for this study was published in advance of its completion [61] and both the protocol and study are reported according to CONSORT guidelines [62]. No changes were made to the conduct of the trial following this but the analytic approach has been amended following advice from a reviewer.1 An a priori sample size calculation carried out using G*Power [63] for the original analytic approach revealed that with 2 groups, 4 measurements, an assumed correlation among repeated measures of 0.3 (typically low in such research; Rossi [64]) as well as a medium effect size (again typical in research on the cognitive effects of mindfulness; Chiesa et al. [42]) and a power of 0.8, the recommended sample size for mixed (repeated-measures and between factors) Noone and Hogan BMC Psychology (2018) 6:13 Page 4 of 18 Table 1 Study Hypotheses Outcomes Variable Measure Primary Mindfulness Five Facet Mindfulness Questionnaire 1 Mindfulness will increase more for the mindfulness meditation (MM) group than for the sham meditation (SM) group from baseline to follow-up Critical Thinking Halpern Critical Thinking Assessment1, Heuristic and Biases items2 2 Critical thinking will increase more for the MM group than for the SM group from baseline to follow-up (a 1,2) and this effect will be moderated by baseline endorsement of thinking dispositions (b1,2) Thinking Dispositions Actively Open-minded Thinking1, Need for Cognition2 3 Endorsement of critical thinking dispositions will increase more for the MM group than for the SM group from baseline to follow-up (a 1,2) Executive Control Sternberg Working Memory Task 4 Executive control will increase more for the MM group than for the SM group from baseline to follow-up (a) and this increase will mediate the relationship between levels of mindfulness and critical thinking performance following the intervention (b) Wellbeing Warwick-Edinburgh Mental Wellbeing Scale 5 Wellbeing will increase more for the MM group than for the SM group from baseline to follow-up Positive Affect and Positive Affect and Negative Affect Negative Affect Schedule subscale 6 Positive affect will increase more and negative affect will decrease for the MM group than for the SM group from baseline to follow-up (a) Real-world Outcomes 7 Negative real-world outcomes will decrease more for the MM group than for SM group from baseline to follow-up 8 Meditation quality will be positively associated with increases in mindfulness (a), executive control (b) and critical thinking (c 1,2) and meditation quantity (d), task enjoyment (e) and task difficulty (f) and it will be higher in the MM group and across time. Meditation quantity will be positively associated with increases in mindfulness (a), executive control (b) and critical thinking (c 1,2) and meditation quality (d), task enjoyment (e) and task difficulty (f) and will not differ across groups. Secondary Real-world Outcomes Inventory Manipulation Meditation Quality Practice Quality-Meditation Checks Hypothesis Meditation Quantity Total Number of Completed Meditation Sessions 9 Task Enjoyment Technology Acceptance Model Questionnaire Perceived Enjoyment subscale 10 Task enjoyment will be positively associated with increases in mindfulness (a), executive control (b) and critical thinking (c 1,2) and meditation quality (d), meditation quantity (e) and task difficulty (f) and will not differ across time or groups. Task Difficulty Technology Acceptance Model Questionnaire Perceived Ease subscale 11 Task difficulty will be positively associated with increases in mindfulness (a), executive control (b) and critical thinking (c 1,2) and meditation quality (d), meditation quantity (e) and task difficulty (f) will not differ across time or groups. Intervention Acceptability Satisfaction items from Kirkpatrick et al. (2013) [84] 12 Intervention acceptability will be positively associated with increases in mindfulness (a), executive control (b) and critical thinking (c 1,2) and meditation quantity (d), task enjoyment (e) and task difficulty (f) and it will be higher in the MM group but will not differ across time. Attrition No. of participants lost from baseline to follow-up 13 Attrition will be negatively associated with meditation quality (a), meditation quantity (b), task enjoyment (c) and task difficulty ANOVA was 56. We expected an attrition rate of 20% from baseline to follow-up based on reported attrition rates of between 20 and 40% [49, 52] for research using the Headspace application and the incentives available in the form of course credit, lunches provided at data collection and free subscription to Headspace for six months following the intervention. With this in mind, we sought to recruit at least 80 participants. Following screening, our baseline sample included 91 participants and attrition led to a follow-up sample of 71 participants. Fig. 1 depicts the flow of participants through the study. Sample characteristics Table 2 presents the characteristics of our sample. Our inclusion criteria specified that university students at NUI Galway who are over 18 years of age, below 65 years of age and have either English as first language or university level English (i.e. equivalent to 80 on TOEFL or 6.5 on IELTS) were eligible for this study. The exclusion criteria included previous experience in meditation, alcohol or drug dependence, current use of sedating medication, history of medical conditions associated with a head injury, spinal injury, Noone and Hogan BMC Psychology (2018) 6:13 Page 5 of 18 Fig. 1 CONSORT [105] flowchart of progress through phases of the current study. Sample size (Incl. flow chart) epilepsy, or stroke, lack of normal or corrected-tonormal vision and hearing and current experience of high levels of depression, anxiety or psychotic symptoms. This last criterion was assessed with the Modified Mini Screen (OASAS [65]). Phone calls were made to debrief people who were excluded and they were offered access to the intervention materials. If any potential participants had exceeded the cut-off score on the Modified Mini Screen, an experienced clinician was available for support. Randomisation Participants accessed the intervention content relevant to their group allocation using a unique code provided by Headspace staff. These codes were initially provided to the researchers in lists labelled “Condition A” and “Condition B”. Participants were randomly allocated to the Condition A or Condition B using block randomisation with a 1:1 ratio and a fixed block of 6 and then given their code by the researcher [66]. Following the completion of data analysis, the Headspace staff Table 2 Sample Characteristics Sham Meditation Mindfulness Meditation Overall Baseline Follow-up Baseline Follow-up Baseline Follow-up N 48 35 43 36 91 71 Females/Malesa 35/13 27/8 34/7 29/5 69/20 56/13 Age – M (SD) 21.06 (4.67) 20.74 (3.43) 20.77 (4.11) 20.39 (3.64) 20.92 (4.39) 20.56 (3.52) Years in Higher Education – M (SD) 1.93 (2.01) 1.87 (2.02) 1.37 (0.93) 1.33 (0.89) 1.66 (1.61) 1.60 (1.57) a Two participants chose not to report their gender Noone and Hogan BMC Psychology (2018) 6:13 informed the researchers which condition the mindfulness meditation group was (i.e. A or B) and which condition the sham meditation group was. Through this procedure, double-blinding was achieved. If it had been necessary for any reason, blinding could have been undone on an individual basis through dialogue between the researchers and the Headspace staff. Intervention All of the intervention content was delivered through the Headspace application. This application can run on any iOS or Android smartphone or tablet and through internet browsers. Once participants had set up an account and entered their unique randomisation code, they could follow a guided meditation session whenever and wherever suited them. The intervention was 6 weeks in duration and participants were requested to complete 30 meditation sessions during this time. Each session lasted 10 min. The sole difference in the experience for participants in the two study groups was the nature of the guided sessions, as described next. Experimental condition The content of the initial sessions in this condition focused on introducing the concept of mindfulness, practical tips for practicing mindfulness meditation and a guided body-scan meditation. Later sessions introduced a breath counting exercise during the guided meditations and developed a greater emphasis on non-judgmental awareness. For a session-by-session description, see Additional file 1. This content was developed and delivered by Andy Puddicombe who is an internationally recognised expert in mindfulness practice and teaching. Active-control condition This condition presented the participants with guided breathing exercises. Each session began by inviting the participants to sit with their eyes closed. These exercises were referred to as meditation but participants were not given guidance on how to control their awareness of their body or breath. This approach was designed to control for the effects of expectations surrounding mindfulness and physiological relaxation to ensure that the effect size could be attributed to mindfulness practice specifically. This content was also delivered by Andy Puddicombe and was developed based on previous work by Zeidan and colleagues [55, 57, 58]. Page 6 of 18 NUI Galway School of Psychology. The Sternberg Working Memory was presented using Inquisit [67] and the remaining measures were presented using SurveyGizmo. No changes were made to the outcome measures used following initial design and registration. Primary outcome measures Reliability analysis for the questionnaires used in this study was conducted using the Scale Diagnosis function from the UserFriendlyScience package in R which allows the examination of Cronbach’s alpha (α), omega (ω) and the greatest lower bound (GLB) [68]. Reliability for each 2-item factor is computed using the Spearman-Brown coefficient [69]. Halpern Critical Thinking Assessment (HCTA; [70]) The HCTA involves 25 real-world involving medical research, social policy analysis and other types of problems encountered in everyday life. Each situation is accompanied by both open and closed questions. A standardised guide answers is used to score forced-choice questions. This guide includes specific scoring prompts for openended questions (for more detail see [71]). The total possible score across all situations is 194 [70]. The internal reliability of the HTCA is usually adequate [15, 71] and was found to be so at both time points in this study (Baseline: Cronbach’s α = 0.72 [0.64, 0.80], ω = 0.73 [0.65, 0.81], GLB = 0.79; Follow-up: Cronbach’s α = 0.81 [0.74, 0.87], ω = 0.81 [0.75, 0.88], GLB = 0.79). Heuristics and Biases items [5] These 16 items were taken from the literature on judgment and decision-making. It has been suggested that they assess aspects of critical thinking not captured by traditional measures (for more detail see [5, 61]). Each of these items was scored as either correct or incorrect so total score of 16 was possible. Though these items do not represent a unifactorial construct, we followed West and colleagues [5] in aggregating the scores on these items and as a result found poor reliability (Baseline: Cronbach’s α = 0.60 [0.49, 0.72], ω = 0.61 [0.50, 0.72], GLB = 0.67; Follow-up: Cronbach’s α = 0.34 [0.24, 0.54], ω = 0.46 [0.36, 0.56], GLB = 0.66) which suggests that multiple processes underlie the rational thinking required by these items. Common to these items, however, is the need to inhibit an automatic heuristic response and this is the process of interest in this study. Five Facet Mindfulness Questionnaire (FFMQ; [72]) Data collection Baseline data was collected during the beginning of the intervention. collected during the week following vention. The data was collected in the week preceding Follow-up data was the end of the interthe PC suite of the The FFMQ includes 39 items across 5 sub-scales tapping separate facets of dispositional mindfulness: describing (Baseline: Cronbach’s α = 0.89 [0.85, 0.92], ω = 0.89 [0.86, 0.92], GLB = 0.93; Follow-up: Cronbach’s α = 0.90 [0.86, 0. 93], ω = 0.90 [0.86, 0.93], GLB = 0.94), observing (Baseline: Noone and Hogan BMC Psychology (2018) 6:13 Cronbach’s α = 0.75 [0.67, 0.83], ω = 0.76 [0.68, 0.83], GLB = 0.87; Follow-up: Cronbach’s α = 0.82 [0.76, 0.88], ω = 0. 83 [0.77, 0.89], GLB = 0.90), non-reactivity (Baseline: Cronbach’s α = 0.82 [0.76, 0.87], ω = 0.82 [0.77, 0.88], GLB = 0.91; Follow-up: Cronbach’s α = 0.77 [0.68, 0.85], ω = 0. 77 [0.69, 0.85], GLB = 0.84), non-judgment (Baseline: Cronbach’s α = 0.88 [0.84, 0.92], ω = 0.88 [0.85, 0.92], GLB = 0.90; Follow-up: Cronbach’s α = 0.92 [0.89, 0.95], ω = 0. 92 [0.89, 0.95], GLB = 0.96) and acting with awareness (Baseline: Cronbach’s α = 0.86 [0.82, 0.91], ω = 0.86 [0.82, 0.91], GLB = 0.93; Follow-up: Cronbach’s α = 0.87 [0.82, 0. 91], ω = 0.87 [0.82, 0.91], GLB = 0.95). Responses are captured on a 5-point Likert scale (e.g. 1 = never or very rarely true; 5 = very often or always true). It has been shown to have adequate internal consistency and construct validity [72]. Sternberg working memory task [73] This task is a measure of executive control of working memory. Participants were required to memorise a series of letters. They then indicated, as quickly and accurately as possible, whether a probe was in this series. There were 54 trials and the number of accurate responses was employed as the dependent variable. This task was used as it had been successfully applied using the Inquisit online experiment software in a previous study on mindfulness and executive control [26] and since it assesses working memory resources which, as described above, are necessary for the engagement of type-2 processes such as critical thinking. Secondary outcome measures Positive and Negative Affect Schedule (PANAS; [74]) This scale was used to assess general levels of positive and negative affect by asking participants to indicate to what extent they felt each of 20 positive and 10 negative emotions over the past week using a 5-point Likert scale (e.g. 1 = very slightly or not at all; 5 = extremely). This scale tends to demonstrate good reliability [75] and this was replicated in the current study for the positive (Baseline: Cronbach’s α = 0.87 [0.83, 0.91], ω = 0.87 [0.83, 0.91], GLB = 0.94; Follow-up: Cronbach’s α = 0.90 [0.86, 0.93], ω = 0.90 [0.86, 0.93], GLB = 0.95) and negative affect subscales (Baseline: Cronbach’s α = 0.86 [0.82, 0. 91], ω = 0.87 [0.83, 0.91], GLB = 0.92; Follow-up: Cronbach’s α = 0.86, ω = 0.86 [0.82, 0.91], GLB = 0.92). Warwick-Edinburgh mental wellbeing scale [76] This 14 item scale assesses subjective well-being and psychological functioning. The scale is scored by summing responses to each item answered on a 5 point Likert scale. The total possible score is therefore 70 and a high score reflects a high level of positive mental health [77]. This scale showed excellent reliability in this Page 7 of 18 study (Baseline: Cronbach’s α = 0.85 [0.78, 0.88], ω = 0.86 [0.78, 0.88], GLB = 0.94; Follow-up: Cronbach’s α = 0.89 [0.86, 0.93], ω = 0.90 [0.86, 0.93], GLB = 0.95). The wellbeing measures were included in order to allow comparison between this study and previous studies which had employed a similar online intervention method to manipulate mindfulness practice. Real world outcomes inventory [16] This is a behavioural checklist focused on negative life outcomes from many domains ranging in severity. It has been shown to be negatively associated with critical thinking (i.e. higher critical thinking performance related to fewer negative outcomes). It was slightly adapted to ensure cultural relevance by omitting items which do not fit the Irish student context (e.g. got blisters from sunburn). The checklist presented participants with 32 possible outcomes and they were asked to indicate whether they had experienced each outcome in the previous 2 weeks. Adherence Objective adherence data was collected through the Headspace accounts of the participants. The number of completed sessions was recorded. Potential moderators Need for cognition scale [78] This unidimensional scale assesses individuals’ tendency to engage in effortful cognitive activity [78]. The scale includes 18 items which are rated on a 5-point Likert scale (e.g. 1 = extremely uncharacteristic of me; 5 = extremely characteristic of me) and has a total possible score of 90. It has been extensively validated and has been found to have adequate reliability [79]. It had excellent reliability in this study (Baseline: Cronbach’s α = 0. 89 [0.85, 0.92], ω = 0.89 [0.86, 0.92], GLB = 0.95; Followup: Cronbach’s α = 0.90 [0.87, 0.93], ω = 0.98 [0.87, 0.94], GLB = 0.92). Actively open-minded thinking scale [80] This scale assesses the extent to which individuals tend to approach information in an open and flexible manner. It includes 41 items which are rated on a 6-point Likert scale (e.g. 1 = strongly agree; 6 = strongly disagree). The total possible score is 246. It has been validated as unidimensional and is found to be reliable [81]. It demonstrated adequate reliability in this study (Baseline: Cronbach’s α = 0.87 [0.83, 0.91], ω = 0.87 [0.83, 0.91], GLB = 0.86; Follow-up: Cronbach’s α = 0.89 [0.85, 0.92], ω = 0.89, [0.85, 0.92], GLB = 0.89). Noone and Hogan BMC Psychology (2018) 6:13 Manipulation checks Participants were asked to complete these manipulation checks online directly following a guided meditation session. A survey containing the following measures was sent to participants’ by email at 2 and 4 weeks following the start of the intervention. Practice quality - mindfulness questionnaire [82] This 6 item questionnaire consists of two factors assessing perseverance (i.e. persistent returning of focus to object of meditation) and receptivity (i.e. a willingness to embrace the experience) during meditation. Participants indicated the percentage of time during their meditation session that day during which their experience reflected each of the item statements. This scale has been shown to fit a 2-factor structure and practice quality predicts improvements in psychological symptoms [82]. Both the perseverance (Week 2: Cronbach’s α = 0.77 [0.62, 0.91], ω = 0.79 [0.67, 0.91], GLB = 0.86; Week 4: Cronbach’s α = 0.67 [0.55, 0.79], ω = 0.79 [0.58, 0.80], GLB = 0.73) and receptivity (Week 2: Cronbach’s α = 0.81 [0.69, 0.93], ω = 0.81 [0.70, 0.93], GLB = 0.82; Week 4: Cronbach’s α = 0.74 [0.64, 0.83], ω = 0.77 [0.69, 0.84], GLB = 0.85) subscales showed adequate reliability. Technology Acceptance Model questionnaire (TAM; [83]) The TAM was employed to assess participants’ perceptions regarding their use of the Headspace app. The scale consists of factors assessing barriers to use (3 items; Week 2: Cronbach’s α = 0.88 [0.84, 0.92], ω = 0.90 [0.86,0 .94], GLB = 0.92; Week 4: Cronbach’s α = 0.87 [0.82, 0.92], ω = 0.88 [0.84, 0.92], GLB = 0.73), perceived ease of use (3 items; Week 2: Cronbach’s α = 0.89 [0.82, 0.96], ω = 0.90 [0.85, 0.96], GLB = 0.91; Week 4: Cronbach’s α = 0.74 [0. 64, 0.83], ω = 0.77 [0.69, 0.85], GLB = 0.79), enjoyment (2 items; Week 2: Spearman-Brown = 0.92; Week 4: Spearman-Brown = 0.87) and intention to use (2 items; Week 2: Spearman-Brown = 0.96; Week 4: SpearmanBrown = 0.95). Items are measured on a 5-point Likert scale (e.g. 1 = strongly disagree; 5 = strongly agree). Intervention acceptability [84] Participants were asked about their overall satisfaction with the intervention and their satisfaction with the guided session content in particular. They were also asked binary questions about whether they would recommend the intervention to a friend and whether it was worth their time. These specific questions have been used to assess the acceptability of a range of low-intensity online interventions [84]. Statistical analysis Hypotheses regarding change in primary and secondary outcome measures from baseline to follow-up were tested Page 8 of 18 in a series of regressions estimated using a full information maximum likelihood approach. These models examined the effect of group assignment on each measure at followup while controlling for baseline measurements. These analyses were conducted using AMOS [85]. Correlations between manipulation check measures were also examined as were their correlations with FFMQ change scores. These analyses were completed using SPSS 20 [86]. Simple mediation analyses were conducted using Structural Equation Modelling (SEM) to test whether executive function, meditation quality and adherence are mediators of any potential relationship between mindfulness and critical thinking. These analyses were also conducted using AMOS [85]. As noted above, these tests will be adequately powered – including SEM analyses (see Iacobucci et al. [87], for evidence of adequate power for simple mediation using SEM in samples as small as n = 30). See Table 1 for the specific tests employed for each hypothesis. Results Descriptive statistics and data inspection Means and standard deviations for each dependent variable are displayed in Table 3. The data were inspected to ensure assumptions for the planned analyses were met. Q-Q plots, histograms and skewness and kurtosis values were examined for each continuous variable to assess normality. This revealed that the distributions of responses at both time points for both real world outcomes and negative affect were positively skewed while scores on the executive function task were negatively skewed. Log transformations were carried out on these variables (with scores on the executive function task being reflected first). Box plots and z-scores were examined in order to identify potential outliers. No significant outliers were identified. Manipulation checks These analyses were carried out to investigate whether any other characteristics of the intervention besides the content may have affected its outcomes and participant adherence and whether the differences in intervention content led to differences in meditation quality. Tables 4 and 5 displays correlations between manipulation check measures and change scores for executive function and critical thinking measures. There are several relationships of note here. Changes in performance from baseline to follow-up on measures of critical thinking and executive function were not related to any manipulation check measures. There were, however, significant positive correlations observed between meditation quantity and increases in HCTA scores and observing in both groups. Meditation quantity was also positively related to task ease and enjoyment for the sham meditation group. In terms of meditation quality, while receptivity was not significantly related Noone and Hogan BMC Psychology (2018) 6:13 Page 9 of 18 Table 3 Means with 95% confidence intervals and standard deviations for primary and secondary measures Sham Meditation Mindfulness Meditation Baseline Follow-up Baseline SD Follow-up M 95% CI SD M 95% CI M 95% CI SD Observing 25.58 [24.06, 27.18] 5.60 27.29 [25.63, 28.93] 5.74 M 95% CI SD 26.63 [25.26, 28.00] 4.83 28.42 [27.13, 29.63] 4.52 Non-reactivity 20.10 [18.87, 21.35] 4.61 21.31 [20.08, 22.60] 4.46 20.37 [18.78, 21.89] 5.08 21.91 [20.60, 23.16] 4.21 Acting with Awareness 23.98 [22.31, 25.82] 6.43 24.60 [22.85, 26.47] 6.37 24.84 [23.30, 26.40] 5.19 24.81 [23.13, 26.42] 5.29 Non-judgment 26.85 [25.06, 28.66] 6.42 28.23 [26.19, 30.14] 7.09 27.02 [24.88, 29.08] 6.24 27.84 [25.96, 29.75] 5.99 Describing 26.17 [24.36, 28.05] 6.71 26.54 [24.55, 28.42] 6.62 26.21 [24.60, 27.86] 5.41 27.77 [26.40, 29.19] 4.94 HCTA 107.81 [104.35, 111.86] 12.10 113.79 [12.01, 16.58] 14.56 107.93 [103.80, 111.78] 12.67 113.49 [108.90, 117.88] 14.90 Heuristics and Biases 7.54 Actively Open-Minded Thinking 181.52 [175.98, 187.18] 18.59 182.98 [17.94, 23.78] 21.29 174.91 [169.65, 180.70] 19.10 179.11 [173.06, 185.04] 20.37 Need for Cognition 63.79 [60.83, 66.96] 10.49 63.54 [8.17, 12.78] 10.69 58.05 [54.33, 61.41] 12.25 58.79 [54.90, 62.36] 13.36 Executive Function 51.15 [50.33, 51.94] 2.90 50.67 [2.66, 4.40] 3.58 50.49 [48.56, 51.88] 4.85 50.65 [49.75, 51.53] 2.87 Wellbeing 49.98 [48.27, 51.71] 6.58 51.15 [5.57, 7.70] 6.82 50.28 [48.21, 52.42] 6.91 53.35 [51.14, 55.65] 7.00 Positive Affect 34.08 [32.13, 35.92] 7.04 35.29 [6.01, 8.00] 7.15 33.81 [31.74, 36.00] 7.32 34.91 [32.41, 37.24] 7.33 Negative Affect 20.17 [18.15, 22.15] 7.29 19.38 [5.17, 7.19] 6.33 18.95 [16.96, 20.97] 7.34 17.65 [15.95, 19.63] 6.59 Real World Outcomes 3.71 [2.96, 4.54] 2.77 3.23 [1.76, 2.94] 2.43 3.12 [2.53, 3.79] 2.06 3.30 [2.70, 3.90] 2.08 [6.85, 8.31] 2.12 7.65 [2.00, 2.54] 2.30 6.95 [6.26, 7.63] 2.35 7.21 [6.56, 7.86] 2.16 Table 4 Means and standard deviations for manipulation check variables and their correlations with change scores Sham Meditation N M SD Mindfulness Meditation ΔHCTA ΔHB ΔSWM ΔOBS ΔNR N M Overall SD ΔHCTA ΔHB ΔSWM ΔOBS ΔNR M 0.36* 0.23 15.26 12.98 0.42 0.07 26.22 30.75 SD Meditation Quantity 48 14.85 12.52 0.53** −0.03 − 0.11 0.47** 0.27 43 15.72 13.61 0.32* −0.13 Week 2 TAM Barriers 21 23.51 29.65 0.25 −0.27 − 0.29 − 0.04 − 0.07 25 28.49 32.08 − 0.07 − 0.18 − 0.03 Week 4 TAM Barriers 35 5.69 − 0.05 − 0.06 0.00 − 0.38* 0.02 1.92 0.08 0.12 −0.09 − 0.39* − 0.03 5.35 Week 2 TAM Ease 21 35.97 31.44 0.17 −0.10 − 0.38 − 0.12 − 0.42 25 31.99 28.24 − 0.12 −0.23 − 0.19 0.22 0.06 33.80 29.48 Week 4 TAM Ease 35 14.00 1.41 0.29 −0.15 −0.15 0.34* 0.03 28 14.04 1.57 0.07 −0.12 0.37 0.21 0.00 14.02 1.48 Week 2 TAM Enjoyment 21 7.52 3.27 −0.13 −0.07 0.18 0.22 0.12 25 8.20 3.33 0.26 0.21 0.07 −0.36 −0.02 7.89 Week 4 TAM Enjoyment 35 9.57 2.34 0.08 0.00 −0.19 0.05 0.24 28 10.86 1.67 −0.08 −0.02 0.09 0.07 −0.13 10.14 2.15 Week 2 Satisfaction 21 3.76 .77 0.10 −0.15 0.04 0.12 −0.14 25 3.96 0.68 0.27 −0.11 −0.04 0.05 −0.03 3.87 0.72 Week 4 Satisfaction 35 3.50 .86 0.00 −0.14 −0.03 0.18 −0.16 28 4.10 0.43 −0.18 0.01 0.12 −0.01 0.05 3.88 0.72 Week 2 PMQ Perseverance 21 61.81 24.07 0.14 0.04 −0.10 −0.14 −0.40 25 67.04 23.17 0.16 −0.15 −0.14 0.05 0.20 64.65 23.47 Week 4 PMQ Perseverance 35 55.43 21.38 0.24 −0.13 −0.14 0.16 0.15 28 64.55 18.81 0.02 0.24 −0.13 0.11 0.14 59.48 20.63 Week 2 PMQ Receptivity 20 62.05 25.31 0.30 0.35 −0.01 −0.05 −0.18 25 70.01 21.75 0.28 −0.17 −0.02 − 0.20 0.09 66.47 23.47 Week 4 PMQ Receptivity 35 72.73 19.13 −0.05 0.15 0.08 −0.20 −0.26 28 72.39 19.00 0.16 0.13 −0.03 0.08 −0.10 72.58 18.92 2.74 28 4.93 0.17 2.42 3.28 Note: Δ = Change score; TAM = Technology Acceptance Model; PMQ = Practice Quality – Mindfulness; HCTA = Halpern Critical Thinking Assessment; SWM = Sternberg Working Memory Task; OBS = Observing Subscale of Five Facet Mindfulness Questionnaire; NR = Non-reactivity of Five Facet Mindfulness Questionnaire * denotes p < .05 ** denotes p <.01 Noone and Hogan BMC Psychology (2018) 6:13 Page 10 of 18 Table 5 Correlations of manipulation check variables for sham meditation and mindfulness meditation groups 1 2 3 4 5 6 7 8 9 10 11 1. Meditation Quantity 1 −0.16 0.06 0.21 0.00 0.03 0.28 −0.01 0.01 0.16 0.16 2. Week 2 TAM Ease 0.60* 1 0.56 0.19 0.31 0.23 0.38 0.66** 0.39 −0.13 0.52 3, Week 4 TAM Ease 0.59 0.59 1 −0.35 0.20 −0.36 −0.03 0.16 0.24 0.21 0.08 4. Week 2 TAM Enjoyment 0.01 0.23 0.22 1 0.31 0.42 0.38 0.32 −0.06 0.33 0.45 ** 5. Week 4 TAM Enjoyment 0.34 0.50 0.58 0.56 1 −0.04 0.12 0.00 −0.29 0.22 0.14 6. Week 2 Satisfaction 0.09 0.31 0.09 0.76** 0.39 1 0.28 0.57* 0.02 0.40 0.32 7. Week 4 Satisfaction 0.13 −0.18 0.28 0.47 0.38 0.66 1 0.69 0.18 0.46 0.23 8. Week 2 PMQ Perseverance 0.04 0.21 −0.25 0.24 −0.09 0.36 0.25 1 0.71* 0.02 0.29 * * * * * 9. Week 4 PMQ Perseverance 0.16 −0.51 0.26 −0.24 0.27 −0.42 0.34 0.90 1 0.35 −0.07 10. Week 2 PMQ Receptivity 0.25 0.33 0.03 0.01 −0.12 0.44 −0.08 0.20 −0.01 1 0.73** 11. Week 4 PMQ Receptivity −0.13 0.70* −0.07 −0.59 − 0.21 −0.13 − 0.19 −0.24 − 0.45** 0.73* 1 * ** Note: Bottom Left quadrant = Correlations for Sham Meditation Group. Top Right quadrant = Correlations for Mindfulness Meditation Group. TAM = Technology Acceptance Model; PMQ = Practice Quality – Mindfulness to any manipulation check measures in the mindfulness meditation group, there was a strong positive association between receptivity and task ease for the sham meditation group. Perseverance was positively related to satisfaction with the intervention for both groups and also to task ease within the mindfulness meditation group. Only 23 participants completed the manipulation check measures at both time points. It was decided that this sample size was insufficient to justify the analysis of differences across time and therefore, contrary to pre-registered analyses, only group differences at each time point are reported. Differences between the mindfulness meditation and sham meditation groups on each of the manipulation check measures at each time point were analysed using a series of independent t-tests. There was no evidence for a difference between the groups in meditation quantity and, on average, participants completed half of the 30 sessions they were asked to complete (t(89) = − 0.32, p = 0.75). Table 6 breaks down this average to show that a third of the sample did not complete any meditation sessions, half of the sample completed at least half of the sessions and a quarter of the sample completed all 30 sessions. Meditation quality consists of two factors focusing on perseverance and receptivity. At week 2 of the intervention, there was no evidence for a significant difference between the groups in either perseverance (t(44) = − 0. 75, p = 0.46, Mean difference = − 5.23 [− 19.30, 8.84]) or receptivity (t(43) = − 1.14, p = 0.26, Mean difference = − 7.96 [− 22.12, 6.19]). Similarly, at week 4, no evidence was found for a significant difference between the groups in terms of perseverance (t(61) = − 1.77, p = 0.08, Mean difference = − 9.12 [− 19.40, 1.16]) or receptivity (t(61) = .07, p = 0.94, Mean difference = 0.34 [− 9.33, 10.01]). Subscales from the TAM were used to assess the extent to which participants found the Headspace app enjoyable and easy to use. There was no evidence found for a difference in terms of either enjoyment (t(44) = − 0.69, p = 0.49, Mean difference = − 0.68 [− 2.65, 1.29]) or perceived ease (t(44) = 0. 45, p = 0.65, Mean difference = 3.98 [− 13.76, 21.72]) at week 2. At week 4, there was a significant difference between the groups in their enjoyment of Headspace (t(61) = − 2.54, p = 0.01, Mean difference = − 1.29 [− 2.30, − 0.27]) with the sham meditation group (M = 9.57, SD = 2.34) enjoying it slightly less than the mindfulness meditation group (M = 10. 86, SD = 1.67). There was no evidence for a significant difference in perceived ease of use at week 4 (t(61) = − 0.10, p = 0. 93, Mean difference = − 0.04 [− 0.79, 0.72]). Evidence for a difference between the groups in overall satisfaction with the intervention was not found at week 2 (t(44) = − 0.93, p = 0.36, Mean difference = − 0.20 [− 0. 63, 0.23]). However, at week 4 there was a significant difference (t(58.63) = − 2.08, p = 0.04, Mean difference = − 0. 36 [− 0.70, − 0.01]) which suggested that the mindfulness Table 6 Percentage of sessions completed by the overall sample and each group separately None At least 1 At least 10 At least 15 At least 20 Complete Overall 31.87 68.13 58.24 50.55 37.36 24.18 Sham Meditation 35.42 64.58 60.42 54.17 37.50 18.75 Mindfulness Meditation 27.91 72.09 55.81 46.51 37.21 30.23
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