Currents in Pharmacy Teaching and Learning 11 (2019) 1022–1028

Contents lists available at ScienceDirect

Currents in Pharmacy Teaching and Learning

journal homepage: www.elsevier.com/locate/cptl

Research Note

Effects of mindfulness meditation on mindfulness, mental well-

T
being, and perceived stress
Irene Zollarsa, Therese I. Poiriera, , Junvie Paildenb
⁎

a
Southern Illinois University Edwardsville School of Pharmacy, Edwardsville, IL 62025, United States
b
Department of Mathematics and Statistics, Southern Illinois University Edwardsville, 1 Hairpin Dr, Edwardsville, IL 62026, United States

ARTICLE INFO ABSTRACT

Keywords: Introduction: The purpose of this study was to investigate the effects of mindfulness meditation
Mindfulness meditation using the Headspace™ app on mindfulness, mental well-being, and perceived stress in pharmacy
Headspace™ students.
Mental well-being Methods: Professional year one (P1), professional year two (P2,) and professional year 3 (P3)
Perceived stress
pharmacy students were recruited to participate. Students were instructed to meditate using the
Health promoting lifestyle
Headspace™ app for at least 10 min per day for four weeks. Students at baseline completed the
health promoting lifestyle profile (HPLP). Data was collected from the pre/post surveys using the
Five Facet Mindfulness Questionnaire (FFMQ), Warwick-Edinburgh Mental Well-Being Scale
(WEMWBS), and Cohen Perceived Stress Scale (PSS).
Results: Ninety-two pharmacy students enrolled in the study. Seventy-percent of the participants
completed the study. Only one participant was excluded in the post data analysis due to non-
adherence with the protocol. The data revealed that for all scales the intervention was associated
with enhanced mindfulness and mental well-being and decreased perceived stress. Further
analysis indicated that controlling for various health promoting lifestyle behaviors preserves the
positive impact of mindfulness meditation as demonstrated.
Conclusions: Mindfulness meditation uniformly and independently improved the participants
overall mental health. The data supports a feasible option for minimizing stress and maintaining
mental well-being in a demanding professional program. This study encourages students in
pharmacy schools to adopt these practices in their curriculum.

Introduction

There appears to be a high level of mental health issues in health professional students such as depression, suicidal ideation,
anxiety, addiction, and eating disorders which are on the rise.1–4 An issue of concern is the lack of mental health education advocacy
for these students. The 2016–2017 American Association of Colleges of Pharmacy (AACP) student affairs standing committee ad-
vocated that schools of pharmacy promote mental wellness and stress management programs.4 The Accreditation Council for
Pharmacy Education (ACPE) 2016 Standards recommend measuring student stress.5 Recently, Zeek et al.6 examined the effects of
sleep duration on academic performance in pharmacy students. Appropriate sleep hygiene does correlate with physical health, mood,
and mental well-being. The use of physical exercise as a stress coping mechanism has also been reported.7 An area gaining in
popularity is the use of relaxation techniques such as meditation or mindfulness to help students in high stress academic

⁎
Corresponding author.
E-mail addresses: tpoirie@siue.edu (T.I. Poirier), jpailde@siue.edu (J. Pailden).

https://doi.org/10.1016/j.cptl.2019.06.005

1877-1297/ © 2019 Elsevier Inc. All rights reserved.

I. Zollars, et al. Currents in Pharmacy Teaching and Learning 11 (2019) 1022–1028

environments.8–15 Mindfulness meditation is being aware of the present moment and not letting external or internal factors be
distracting.16 It is a state in which one is highly aware and focused on the reality of the present moment, accepting and acknowl-
edging it, without getting caught up in the thoughts or emotional reactions surrounding the situation. Kabat-Zinn16 states “Meditation
does not involve trying to change your thinking by thinking some more. It involves watching thought itself”. The use of a smartphone
app to perform meditation is also an exciting area of exploration. One app that has been studied in the literature is the Headspace™
app. A study showed that the use of this app reduced depressive symptoms in its participants.17 Another study used this app to
evaluate critical thinking and key thinking dispositions in university students as well.8
Meditation has been proven to have a variety of health benefits, an example of such is stress reduction.9–12,15 In reviewing the
literature, there are a few studies that show how meditation can impact students in the healthcare field. One study of mostly female
medical and psychology students showed that the female students who meditated reported significant positive improvements in
mental distress and study stress.9 Another study from Thailand showed meditation significantly reduced anxiety and stress levels in
nursing students.10 One study in medical students showed a reduction of stress and enhancement of well-being with meditation.11
Another study in medical students supported these findings.12 It was done at 15 US institutions who offer small supportive groups
with meditative practices to their students. By participating in the groups, medical students reduced stress, enhanced their edu-
cational experience, and became more confident and optimistic about their future.12 Another study showed that mindfulness
helped improve burnout symptoms, relaxation, and life satisfaction in nursing students.13 However, there is limited data about
pharmacy students. The pharmacy literature included a focus group of pharmacy students that stated they would welcome
mindfulness-based interventions for stress coping.18 Lemay et al.19 reported on a small group of pharmacy students who parti-
cipated in a yoga and meditation program once weekly where enhanced mindfulness and decreased stress and anxiety were
observed. However, the use and evaluation of an app to facilitate meditation in a large sample size of pharmacy students is not
described in current literature.
The purpose of this study is to evaluate the effects of mindfulness meditation using the Headspace™ app in pharmacy students at
Southern Illinois University Edwardsville School of Pharmacy on mindfulness, mental well-being and perceived stress. The influence
of health promoting lifestyle behaviors, adherence, and demographics like program level, gender, and age group are also examined
on the outcome measures.

Methods

Pharmacy students from the first professional year (P1), second professional year (P2), and third professional year (P3)
classes of a 2–4 program with access to a smartphone were recruited to participate in the study. For the recruitment of this study,
flyers were circulated, and emails were sent to all students announcing the start date for participation in the project and pro-
viding a brief description of the project and incentive information. During a lunch meeting at the end of fall 2017, students were
informed about the study purpose and benefits of mindfulness meditation. Students who practiced daily meditation were ex-
cluded from the study in order to evaluate the impact of starting meditation practices in those who are inexperienced. One-month
subscriptions to the Headspace™ app and a $25 Amazon gift card were provided as incentives for participation and adherence to
the study protocol. Lunch was provided for the three meetings including the informational, enrollment, and final survey com-
pletion sessions.
Students enrolled by completing baseline surveys and attending a training session on mindfulness meditation and use of the
Headspace™ app during the second week of January 2018. After enrollment, the primary method of communication was the pre-
and post-sessions, as well as email communication. The training session was run by the primary author of this study and included
describing how to perform the specific kind of meditation called mindfulness meditation using the app, which has basic sessions
that are designed for beginners to mindfulness meditation. The training session began with the participants taking the baseline
survey before starting any discussion on meditation. After this, a description of mindfulness meditation was provided, and then a
training on the app was completed including where different sessions were in the system, how to set reminders if needed, and
where the adherence information was stored. The Headspace™ app itself provides explicit instructions for how to complete
mindfulness meditation during each session (e.g., a voiceover tells you when to close your eyes, how to breathe, etc.). The study
participants could choose whichever meditation session or packs from the library that they wished to complete. It was suggested
by the authors to start with the first basic pack and go from there, but ultimately it was the participants' decisions. Following
this, a study timeline reminder was provided, including describing the study expectations of meditating for at least 10 min
daily for 4 weeks, what date to start meditation, when to stop meditation (if participants wanted), and when the last session was
to fill out the post-surveys. An incentive reminder was also provided (i.e., a $25 Amazon gift card, free app access, and free food
at both sessions). The Headspace™ app was an ideal choice due to its ability to track time spent meditating, its variety of
meditation topics, and its focus on using mindfulness meditation. A subscription to the app cost $8 per month for an annual
subscription.
The baselines surveys consisted of the well-known and validated Health Promoting Lifestyle Profile (HPLP), Five Facet
Mindfulness Questionnaire (FFMQ), Warwick-Edinburgh Mental Well-Being Scale (WEMWBS), and Cohen Perceived Stress Scale
(PSS) to measure factors that influence stress and mental well-being, mindfulness, mental well-being, and perceived stress

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respectively in participants at baseline.20–23 The HPLP helps measure confounding variables and has six subscales including health
responsibility, physical activity, nutrition, spiritual growth, interpersonal relations, and stress management. The FFMQ helps
measure mindfulness and has five domains: the ability to observe, describe, act with awareness, be nonjudgmental, and non-
reactive. The WEMWBS measures mental well-being as a numeric value. Lastly, the PSS measures perceived stress as a numeric
value. These were administered via Qualtrics™ survey software before the intervention took place. Students were then instructed to
meditate for at least 10 min per day for four weeks using the Headspace™ app. The minimum of 10 min per day was chosen because
the existing literature reviewed had similar time limits. It also allowed for convenience for the participants as they have busy
schedules and 10 min was a reasonable time to ensure study adherence. Time of day did not matter as students were encouraged to
find a time during the day to meditate that best fit into their schedule. Students were also required to keep a self-reporting log to
measure meditation adherence as a backup in the case of app failure and as a way for the researchers to confirm the data from the
app. Adherence was based on the total reported minutes spent meditating. One-hundred percent adherence was defined as 280 min
and anything < 280 min was calculated as a percent. Data reported on total time using the app from the individual app profiles
was used to confirm the self-reporting adherence data. Adherence to the protocol was defined as 75% or higher. As there is no
acceptable minimum adherence level in clinical trials, the percentage of 75% was chosen as this is generally considered a passing
score for examinations.24
After the 28-day study period, another luncheon meeting was held to record adherence patterns using the Headspace™ app and
the self-reporting logs and for students to complete the FFMQ, WEMWBS, and PSS surveys. A unique identifier was used to match pre
and post paired intervention data. The project was determined to be exempt when approved by the Institutional Review Board (IRB).
Statistical Package for Social Sciences (SPSS™) Version 23 was used to perform the statistical analysis.25 Descriptive statistics, and
paired t-tests were used to answer our primary objective which was to examine the effects of mindfulness meditation intervention on
mindfulness, mental well-being and perceived stress scores. With a usable sample of size of 64, an effect size of d = 0.5, and a
Bonferroni corrected required level of significance of alpha = 0.007, the paired t-tests have a 93% power of detecting a significant
change. Regression analysis was done to control for the effects of the aggregated HPLP score on mindfulness, mental well-being and
perceived stress scores. Regression analysis were also used to check whether the degree of adherence (< 100% adherence vs ≥100%
adherence) influenced post-test mindfulness, mental well-being and perceived stress controlling for pre-test mindfulness, mental well-
being, and perceived stress. Correlations between mindfulness to perceived stress and mental well-being were also examined
(d = 0.3, alpha = 0.05, power = 64%).

Results

Ninety-two pharmacy students enrolled in the study. Sixty-five students completed the project. The dropout rate was 29.3%
(N = 27). One pharmacy student's data was eliminated, as the student was not adherent with the protocol. No students were
eliminated due to history of practicing meditation daily. Usable data was available from 64 students. This included 30 P1s (46.9%),
17 P2s (26.6%), and 17 P3s (26.6%). Additional demographic data revealed fifty-five women (85.9%) and nine men (14.1%) as well
as 51 students (79.7%) aged 18–25 years old and 13 students (20.3%) older than 25 years old.
Table 1 represents data for the primary objective and indicates the means of the FFMQ, WEMWBS and PSS at baseline and after
participating in mindfulness meditation for the study period. The data revealed that for all scales the intervention resulted in en-
hanced mindfulness and mental well-being and decreased perceived stress. Table 1 also presents the common language (CL) effect
size for the FFMQ, WEMBWS, and PSS. For a student with similar demographics in the study, there is a 77% (average over five scales)
chance that the FFMQ scale is higher after the intervention. Also, there is a 78% chance that WEMBWS is higher, and a 74% chance
that PSS is lower after the intervention. Furthermore, regression analysis indicated that the inclusion of aggregated HPLP scores as a
covariate preserves the significant positive impact of the intervention on mindfulness and mental well-being, and perceived stress

Table 1
Survey means of both pre and post intervention FFMQ, WEMWBS, and PSS Scales. (N = 64 students).
Pre-mean (SD) Post mean (SD) Cohen's d CL effect size p-Valuea

FFMQ total
Observe (I = 8) 24.1 (4.9) 28.5 (4.7) 1.1 87.3% < 0.001
Describe (I = 8) 26.1 (5.9) 28.8 (4.5) 0.6 72.7% < 0.001
Act awareness (I = 8) 22.4 (5.1) 26.0 (4.6) 0.7 75.4% < 0.001
Nonjudge (I = 8) 23.5 (6.6) 280 (6.0) 0.6 72.9% < 0.001
Nonreact (I = 7) 19.6 (4.5) 23.1 (4.2) 0.7 77.3% < 0.001
WEMWBS (I = 14) 46.5 (7.3) 51.7 (7.3) 0.8 77.7% < 0.001
PSS (I = 10) 20.9 (6.2) 16.8 (5.2) 0.6 73.7% < 0.001

I = number of questions, CL = common language effect size.

a
Paired-samples t-test was used to determine significance, defined as p < 0.007, Bonferroni corrected for multiple comparison.

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Table 2
Evaluation of perception of mindfulness meditation.
None at all % (N) A little % (N) A moderate amount % (N) A lot % (N)

How much value in mindfulness meditation do you see 0 10.9 (7) 53.1 (34) 35.9 (23)
for yourself?
How much do you feel this experience has enhanced 1.6 (1) 31.3 (20) 53.1 (34) 14.1 (9)
your learning abilities?
How much value in mindfulness meditation do you see 0 21.9 (14) 57.8 (37) 20.3 (13)
for your future patients?

Extremely unlikely Somewhat unlikely Neither likely nor unlikely Somewhat likely Extremely likely

How likely are you to continue practicing 0 15.6 (10) 6.3 (4) 51.6 (33) 26.6 (17)
mindfulness meditation?

(data not included).

The influence of the degree of adherence as measured by percent of adherence of self-reported minutes did not result in significant
differences in FFMQ (beta = −0.12, p = 0.32), WEMWBS (beta = −0.16, p = 0.14), or PSS (beta = 0.02, p = 0.84) after con-
trolling for the corresponding pre-test scores. Additionally, the self-reported minutes matched with the data from the app for all
participants. Of note, there was little variation in percent adherence. We had 64 of the 65 participants that were considered adherent
which was defined as 75% or more of required meditation time during the study period. The majority were 100% adherent or more
(N = 54; Mean = 108.3% or 314.1 min; SD = 12.6% or 36.5 min) with the rest being between 75% and 100% (N = 11;
Mean = 81.8% or 237.2 min; SD = 28% or 81.2 min).
The relationship between HPLP scores and its domains to FFMQ, WEMWBS, and PSS was examined with the calculation of
Pearson's correlations. Positive moderate correlations were observed between HPLP scores and FFMQ baseline (R = 0.48, p < 0.01),
and between HPLP scores and WEMWBS baseline (R = 0.54, p < 0.01). This suggests that students with high HPLP scores tend to
have higher FFMQ and WEMWBS baseline scores, and vice-versa. Negative strong correlation was observed between FFMQ and PSS
baseline (R = −0.65, p < 0.01), and WEMWBS baseline and PSS baseline (R = −0.68, p < 0.01); which means that students with
high FFMQ or WEMBWS baseline scores have low PSS baseline, and vice-versa.
We compared the baseline HPLP, FFMQ, WEMWB, and PSS scores for the 28 students who were either dropouts or did not
complete the study to the 64 students who completed the study and were adherent using an independent t-test. The results indicated
no significant differences in baseline scores for these measures (PSS, WEMWBS, FFMQ, and HPLP). Table 2 reports the evaluation of
the participants' perception of practicing mindfulness meditation.

Discussion

Our results show that mindfulness meditation does result in enhanced mindfulness and mental well-being and lower perceived
stress. Of note, this timeframe did take place during finals week for our P2 and P3 students, and yet still showed significant results.
It also shows that those students with higher HPLP scores are more likely to have higher mindfulness, mental well-being, and lower
stress. However, the other lifestyle factors as measured by HPLP scores did not influence the effects of mindfulness meditation. This
means that mindfulness meditation significantly impacts stress, mindfulness, and mental well-being independent of these factors.
These positive results of mindfulness meditation are similar to the Lemay et al.19 study in terms of stress and mindfulness, although
they did not include the influence of various dimensions of the HPLP. This study also examined the influence of using an app to
facilitate mindfulness meditation which may be more practical and feasible for students than participating in guided yoga and
meditation sessions noted by Lemay et al.19 The app has a variety of topics (e.g., stress, sleep, anxiety, etc.) for students to choose
based on their preference and the flexibility of when to use the app for meditation instead of during scheduled times during the
week, making it a more practical choice. The app is relatively inexpensive and is affordable for pharmacy schools to purchase or
even college students. Pharmacy schools would likely get a discount if they purchase a large amount of subscriptions. However,
there are also free meditation apps that could be used as well. Headspace™ was utilized for its ability to store adherence in-
formation.
These study results are generalizable to other pharmacy student populations as the demographic profile is similar to other U.S.
pharmacy programs. The study group included more P1 students than P2 and P3 students. However, even though there are per-
ceptions that the P2 academic year is the most stressful of all years in our program due to the beginning of the integrated biomedical
therapeutics sequence, the baseline PSS and WEMWBS data from the study population does not support a significant difference in
stress levels nor mental well-being across academic years.

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In this study the mindfulness meditation intervention had a significant impact independent of gender or academic year. A review
by O'Driscoll et al.18 also cited no significant differences in terms of stress or mindfulness between genders. However, differences
related to gender and depression scales have been documented. Research from Rojiani26 in college-aged participants reported that
women had higher FFMQ scores than men after completing a mindfulness meditation intervention. The sample size in our study was
small for men. In particular, a larger number of students based on demographics, such as gender, age, pharmacy year, may allow
determining whether there would be differences between the groups and would be an excellent area for future research.
This study is unique in that we examined the influence of other variables that can affect mental well-being and perceived stress.
Administering the HPLP scale which measures other factors that influence stress and mental well-being and evaluating these in-
fluences on the measured intervention outcomes provided a more rigorous study design. The HPLP has six subscales including health
responsibility, physical activity, nutrition, spiritual growth, interpersonal relations, and stress management.20 By administering the
HPLP at baseline, this study allowed for evaluating the influence of these potential confounders on mental health.
We also used other previously validated and widely used outcome scales to measure the impact of the studied intervention. The
FFMQ is a measure of how mindful a person is and consists of five domains. The domains include the ability to observe, describe, act
with awareness, be nonjudgmental, and non-reactive.21 The results of our study demonstrated that all domains of mindfulness were
impacted by the intervention.
The WEMWBS is a measure of the state of a person's mental well-being. The WEMWBS average score from 2011 in England was
reported to be about 51, which shows that our study population had a lower baseline mental well-being than what is considered
average. Thus, using an intervention to address mental well-being would be even more important as the study subjects demonstrated
lower levels of mental well-being than other general populations.22 In these other populations with higher levels of mental well-
being, the outcomes observed may not be generalizable.
The PSS is a measure of stress within the past month. The average score is 13 with high stress being a score of 20 or higher.23 The
average PSS score before the study intervention was about 21 which again confirms that students in professional programs like
pharmacy are under high stress. In a study from Warnecke et al.27 dealing with a mindfulness intervention in medical students, the
average PSS at baseline was 15.7, which is still above average yet not considered high stress like our study. It also dropped about 3.5
points post-intervention which is similar to our results.
The presence of about a 30% dropout rate in the intervention study is not unexpected. Reasons for the dropout are unclear.
Perhaps these students were under more stress than others. However, the baseline comparisons of the dropouts with the study
participants did not reveal significant differences in baseline scores for all the measures. The dropouts could serve as a control group
if we had administered the post-intervention surveys. Administering the post-interventions surveys to these students and comparing
to students who completed the study may have provided a more robust control group.
The results of Table 2 indicate that students have a high perception of the benefits of mindfulness meditation and its value for both
themselves and their patients. These results are like that of O'Driscoll et al.'s18 research in that pharmacy students see a role for
mindfulness interventions to help cope with stress. The numerous benefits and favorable perception of mindfulness meditation
suggests that this is an intervention that should be incorporated into pharmacy schools and other professional schools. Research from
Kinser et al.28 showed that incorporating mindfulness in an interprofessional course with various health care disciplines including
pharmacy resulted in lower perceived stress, anxiety, and burnout. This is an example of how this practice can easily be incorporated
into curricula. In our study, use of an app shows great promise as well.
A potential limitation to this study is using a quasi-experimental design, and the study population being made up of volunteers
who were not randomly selected to the study or a control group. The self-selection bias in this study population probably represents
students who were more motivated to address their mental health. It is possible that the $25 gift card incentive could have also biased
the subject selection.
A randomized study with a control group, instead of a quasi-experimental design like our study, would provide stronger evidence
of the benefits of mindfulness meditation. This is an area for future studies.
Another limitation is the potential incentive bias. Even though all participants that were adherent received the incentive re-
gardless of their perceived benefit from the meditation, it could have influenced them to state that they noticed a difference over the
course of the study. Additionally, this study only lasted for a month and more long-term data would have been ideal. Future studies
over longer timeframes and with multiple time periods would be helpful.
Lastly, an additional perceived limitation could be the use of personal reporting of meditation minutes. However, this study also
used the Headspace™ app to keep track of total minutes of meditation to confirm adherence. Although, that has its own limitations as
well. For example, using the app does not guarantee that the participants were actually doing mindfulness meditation while listening
to the app as they could have just switched it on and not meditated. It is hard to find a solid way to track adherence with complete
certainty, but we felt that using two different ways of checking adherence helped address some uncertainty.
Nevertheless, the data provided and the control for confounders affecting mental health provides some level of evidence for the
benefits of incorporating mindfulness meditation in a highly stressful academic program like pharmacy.

Conclusion

Overall, this project should encourage students to focus on their mental health through an intervention like mindfulness
meditation. The results show that mindfulness meditation is associated with enhanced mindfulness and mental well-being, as well

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as decreased stress. Future studies with long-term data, control groups, and larger groups with varied demographics would help to
support these results. These benefits could help improve student mental well-being and allow them to possibly improve their
performance in school and in the healthcare field. This also shows the feasibility of pharmacy schools adopting a mindfulness
meditation program using a phone app for the mental health of their students. If students start practicing and see the benefits of
meditation, it would possibly lead to them recommending it to their colleagues as well as future patients, with potential health
benefits to all.

Disclosure(s)

None.

Declaration of Competing Interest

None.

Acknowledgements

This research was supported by a Southern Illinois University Edwardsville School of Pharmacy research grant.

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