Clinical Issue
The UP priest community has identified several unaddressed health issues, including a desire for more frequent BP monitoring. Hypertension is the leading risk factor of mortality and the third leading factor of disability-adjusted life years in the world, afflicting an estimated 60 million adults in the United States (Chocalingam, Campbell and Fodor, 2006; Kearney et al., 2005; Hughes et al., 2013). Literature reflects that clergy, especially Catholic clergy, may be vulnerable to cardiovascular health disparities. One study of 3,000 clergy found higher incidence of hyperlipidemia and hypertension than that of the general population (Koller, Blanchfield, Vavra, Andrusyk, & Altier, 2012). A separate study of clergy revealed a higher number of self-reports than the general population of chronic disease related to hypertension and angina (Koller et al., 2012). Many priests manage busy schedules and would benefit from a feasible and simple intervention to protect against hypertension. Literature supports the intervention of Mindfulness Based Stress Reduction (MBSR) as one practice leading to reduction in blood pressure.
Background and Significance
Research promotes MBSR as an affordable, simple, and effective way to ease psychological symptoms and subsequently reduce blood pressure and autonomic responsiveness (Ditto, Eclache, and Goldman, 2006; Campbell, et al., 2012; Palta, et al., 2012). MBSR has been explored in a variety of populations across the world (Ditto, Eclache, and Goldman, 2006; Campbell, et al., 2012; Palta, et al., 2012). While no studies specifically focus on religious communities, the consistency of positive findings across such a cultural and geographic variety promotes generalizability of these results. MBSR can be a feasible intervention engaging the priest population in a simple and contemplative practice.
Purpose, Aim, and Research Question
The primary aim of this pilot study was to understand the effect of a mindfulness-based intervention on BP and stress in participants. The primary purpose was to offer low-cost, simple, and feasible methods of enhancing BP among communities in which some individuals do not receive consistent medical care. This study seeks to answer the following question: In the community of focus, how does mindfulness training compared with no mindfulness training affect BP and perceived stress over a time period of eight weeks?
Methods
Participants
The study was approved by the UP Institutional Review Board. Enrollment began in January of 2018. This was a volunteer-based study in which participants were recruited by a flyer distributed in a common gathering space and by email. Eleven priests of ages 27-95 who were interested in learning stress reduction and mindfulness techniques elected to participate. The only eligibility requirement was that the participant was a CHC member, in residence at UP. All participants provided informed consent.
Intervention
The intervention, a mindfulness-based seminar, involved two one-hour of interactive mindfulness sessions, led by Donald Altman, a psychotherapist, former Buddhist monk, and author on multiple literary works on mindfulness. Altman’s experience as a spiritual practitioner was an asset, augmenting engagement paralleling eastern and western faith practices. Topics involved mindfulness neurobiology, physiologic benefits and spiritual origin. The speaker then introduced participants to mindfulness postures and walking mindfulness.
Measures
Implementation occurred over eight weeks. On week one, participants attended a 30-minute intake for a pre-intervention assessment performed by the principal investigator (PI). At the pre-intervention assessment, the participant completed an intake form, consent form and Perceived Stress Scale (PSS). After the intervention, participants were asked to practice mindfulness three minutes, three times a day. Weeks four, five, six, and seven involved 20-minute sessions to obtain BP and complete a weekly mindfulness log. On week eight a final BP and PSS were obtained.
Blood Pressure. The PI obtained an initial BP through an automatic cuff according to American Heart Association (AHA) guidelines. Prior to measurement, the participant sat quietly for five minutes with legs uncrossed. Three BP measurements were then obtained on the same arm, each separated by two minutes. The Omron BP629 was used, an automated sphygmomanometer validated through the European Society of Hypertension International Protocol and The Association for Advancement of Medical Instrumentation. The PI also provided an educational handout from AHA on BP.
Stress. The PSS was used to measure perceived stress in participants at baseline (week one) and at the end of the eight-week implementation period. The PSS is valid and reliable tool (Roberti, Harrington, and Storch, 2006)
Results
Pre and post measures of both BP and PSS were compared through data analysis. Statistical Package for the Social Sciences (SPSS) was used to perform 2-tailed t test and a repeated measures analysis of variance (RM-ANOVA).
Independent t test. An independent two-tailed t test was conducted to evaluate the hypothesis that the participants’ post-intervention SBP, DBP, and PSS would show a significant reduction compared to the respective pre-intervention SBP, DBP, and PSS. Indeed, as compared to the pre-intervention SBP and DBP, participants showed a statistically significant reduction in both categories (Table 1). Similarly, participants’ DBP and PSS after the mindfulness intervention demonstrated statistically significant reduction (Table 1).
RM-ANOVA. An RM-ANOVA was conducted to examine the effects of mindfulness meditation on DBP over a period of eight weeks. Results indicated a significant difference among the six time points (Table 2). Planned contrasts with a Bonferroni correction revealed that average diastolic DBP during week 1 significantly differed from average DBP during week 8. An RM-ANOVA was conducted to examine the effects of mindfulness meditation on SBP over an eight-week period, revealing no statistically significant correlation (Table 3).
Discussion of Results
Reduction in both SBP and DBP from week one to week eight exceeded 5 mmhg. Whelton et al. (2002) posits that BP reduction this minimal correlates with reduction in stroke, coronary heart disease, overall mortality. These findings emphasize the public health significance of a simple daily practice.
The RM-ANOVA DBP shows a statistically significant difference across the six time points measured. While it is unclear as to why the RM-ANOVA was significant for DBP and not SBP, these findings do not demonstrate typical reduction of treatment effect, even six weeks after intervention. This unique finding favoring effect in the later weeks suggests that quality of mindfulness practice may mature over time. Priests reported greater levels of fatigue over weeks 7 and 8 of the study due to end-of-semester academic demands as well as holy week responsibilities (homilies, confessions, attendance of events). Amidst this, a statistically significant reduction in BP could reflect the resiliency to stressors that mindfulness brings.
Summary and Implications
These pilot results are consistent with previous studies examining the effectiveness of mindfulness-based interventions, showing reduction of BP and stress after implementation of mindfulness practice. This pilot study adds to research by suggesting that mindfulness moments as minimal as three minutes, three times daily, may yield physiologic benefits. This study also presents the value of mindfulness in a population with established spiritual practices. Many Catholic practices such as prayer and the rosary involve moments of stillness, but the mindfulness tools used in this study harnessed the physical with the spiritual.
Limitations
This study could not control for antihypertensive medication adjustment, or tobacco use by participants prior to BP measurement. Challenges to internal validity include variability in timing of BP checks, small sample size and participant age variance. BPs were acquired at different times of day based on participant availability, and not consistently checked on the same arm. Selection bias may exist as volunteer sampling may reflect higher levels of motivation than that of the general priest population. Lastly, the number of documented minutes is self-reported, and increases risk of less accurate reporting.
Conclusion
The motivation and change demonstrated by members of the community may set a tone for future sustainability, promoting a culture of health that lasts past implementation. Flottorp et al. (2013) emphasizes the importance that social norms and context have in regards to sustainability of practice change. Future initiatives driven by this understanding will further promote the health of this community.