key: cord-0885572-v7ci3jce
authors: Xu, J.; Jo, H.; Noorbhai, L.; Patel, A.; Li, A.
title: Virtual mindfulness interventions to promote well-being in young adults: A mixed-methods systematic review
date: 2021-04-27
journal: nan
DOI: 10.1101/2021.04.24.21256035
sha: a2fbb6c0a0e1d9583804282c17c2c99b853effa3
doc_id: 885572
cord_uid: v7ci3jce

Background With the onset of the COVID-19 pandemic, students have experienced drastic changes in their academic and social lives with ensuing consequences towards their physical and mental well-being. The purpose of this systematic review is to identify virtual mindfulness-based interventions for the well-being of young adults aged 15 to 40 years in developed countries and examine the efficacy of these techniques/exercises. Methods This mixed-methods systematic review follows the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines with a registered PROSPERO protocol. With a convergent integrated synthesis approach, IEEE Xplore, PsychInfo, Web of Science and OVID were searched with a predetermined criteria and search strategy employing booleans and filters for peer-reviewed and grey literature. Data screening and extraction were independently performed by two authors, with a third author settling disagreements after reconciliation. Study quality of selected articles was assessed with two independent authors using the Mixed Methods Appraisal Tool (MMAT). Studies were analyzed qualitatively (precluding meta and statistical analysis) due to the heterogeneous study results from diverse study designs in present literature. Results Common mindfulness-based interventions used in the appraised studies included practicing basic mindfulness, Mindfulness-Based Stress Reduction (MBSR) programs, Mindfulness-Based Cognitive Therapy programs (MBCT) and the Learning 2 BREATHE (L2B) program. Conclusion Studies implementing mindfulness interventions demonstrated an overall improvement in well-being. Modified versions of these interventions can be implemented in a virtual context, so young adults can improve their well-being through an accessible format.

greater awareness of the present, individuals may confront and accept feelings of stress, anxiety, fear, hate, sadness with greater ease. Unhealthy ways of coping, suppression of stress, mental breakdowns, burn out, and physiological issues from chronic stressors can result from maladaptively addressing these negative emotions [2] . The significance of mindfulness interventions are explored within research, but a gap in the present literature remains within virtual integrations of these interventions specifically targeted towards young adults.

Therefore, this systematic review assesses effective strategies to improve well-being within an academic context for young adults from ages 15 to 40 years old. By identifying, appraising and integrating present literature, mindfulness-based interventions can be evaluated for most desirable outcomes. This mixed methods systematic review aims to answer the following research question: What mindfulness-based interventions can be integrated into a mobile application to promote well-being of individuals (students) between the ages of 15 to 40 years old? These findings may be integrated into the Felicity App, a virtual application targeting students in developed countries to provide productivity enhancement techniques through a mobile and web application. Productivity incorporates several facets, where well-being serves as an important aspect to improve productivity and proactively prevent demotivation and burnout by managing stress levels.

A systematic review was conducted to assess mindfulness interventions in the context of well-being for students to improve productivity, motivation, and overall mental health. The current review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [67] and the protocol is registered in PROSPERO, an international database of prospectively registered systematic reviews in health and social care.

Virtual mindfulness interventions that can improve students' well-being were examined through this systematic review. The virtual element of these interventions may allow for multi-media incorporation, such as within a mobile application to help students improve their emotional and academic experience. Apps allow for interactive participation, accessibility and flexibility of options. Statistics Canada has determined that many people 15 years of age and older own a smartphone and 45.4% of those individuals check it every 30 minutes [4] . Thus, a smartphone app is accessible and virtual interventions through mobile apps can be seamlessly integrated into the lifestyles of this age demographic. The target audience for this application are young adults between 15 and 40 years of age in developed countries located in North America, Asia, Australia and Europe.

A mixed method study design was used to ensure qualitative and quantitative elements of the mindfulness-based intervention strategies are included in the systematic review. Quantitative data provides measurable information on how mindfulness-based interventions improve cognition and overall well-being for students. Qualitative data allowed for identification of patterns observed with mindfulness-based interventions and the perspectives associated with different intervention methods. Both forms of data are important to ensure the most effective mindfulness-based interventions are integrated and that optimal well-being strategies can be used by users. Due to the diverse study designs, subsequent study findings have shown significant heterogeneity and statistical analysis is precluded by qualitative analysis.

IEEE Xplore, PsychInfo, Web of Science, ProQuest and OVID were searched for articles published between January 1980 to January 2021, using keywords related to mindfulness, productivity, wellness, and cognition in students. A broad range of synonyms were used to ensure all relevant studies were included in the search, with accompanying filters and booleans (refer Appendix 1 for the full search strategy and Appendix 2 for the grey literature search strategy).

For the implementation of grey literature, a search for articles was conducted in various databases and websites, specifically the National Center for Biotechnology Information (NCBI) and the Web of Science. The snowballing method was used to search Google Scholar to identify additional sources from references cited in conference proceedings and web pages.

The search strategy was created by using keywords with different booleans and truncations. The specific words " mindfulness and student*, learn*, burnout or stress or motivat*, productiv*, cognit*, atten*, creativ*, virtual, intrinsic were used for extraction. Other specific words such as teacher or professor or kindergarten or children or ADHD or GAD or TBI or injury aided in excluding material through the "not" function. This comprehensive set of sources were processed with more advanced screening to attain the most relevant literature. Specific filters were added to databases to screen full-texts when possible.

The predetermined criteria for inclusion includes psychology studies published in English between 1980 to January 2021. Eligible study designs included randomized controlled trials (RCTs), meta-analyses, systematic reviews, and grey literature. To be included, studies must mention the impact of mindfulness interventions on any of the following: motivation, burnout, stress, learning, cognition, and productivity related topics. These interventions must be virtually transferable and excluded individual therapy. The study participants were young adults between ages 15 to 40 of all genders, and residing in North America, Europe, Asia, or Australia. Studies with interventions targeted to individuals with a physical illness, mental illness, or learning disability were excluded. Any articles that were not available online and were published by organizations with conflicts of interest were also excluded from this systematic review (refer to Appendix 4 for a list of excluded studies).

A predetermined, piloted screening tool was developed using the inclusion and exclusion criteria. The screening tool ensured that only relevant data would be collected from abstracts and full text articles. The pilot trial of the screening tool prompted necessary revisions to improve precision. Modifications to the tool were prompted by discussions during reconciliation.

A total of 915 articles were initially searched, with findings consisting of 71 grey literature and 844 peer reviewed articles. The database search results were combined, and duplicate articles (n=20) were removed manually using Endnote (version 8) prior to the screening phase. Within study selection, titles and abstracts of 895 articles were screened by two independent authors on January 31, 2021. Any disagreements between the two independent authors were reconciled and disagreements were resolved with a third author. Prior to full-text screening, 3 grey literature and 116 peer-reviewed articles proceeded towards full-text screening with two independent authors, reconciliation, and a third author for resolving disagreements. After full text screening of the initial papers, a total of 22 studies remained.

Upon initial study selection, reference lists of included articles were hand searched and screened for potential inclusion. During the first round of hand search screening, 1302 peer reviewed articles went through abstract screening by two independent authors using the piloted screening tool to produce 57 papers. Full texts were screened independently by the two authors, then reconciled to resolve any disagreements with a third author for resolution. In total, 17 studies from hand searches were included. Data extraction was performed in duplicate with two independent authors, with study characteristics including author, title, study duration, study population, location, intervention methods and results. In total, 39 studies were included in this systematic review.

The Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of the articles included in the study. The MMAT is a critical appraisal tool used to assess qualitative, quantitative, and mixed methods studies. The MMAT provides an effective measure to appraise a wide variety of empirical studies. The tool has been tested for reliability and content validity, however, the literature on the quality of the MMAT lacks consensus. Articles are organized into five categories: (1) qualitative research, (2) randomized controlled trials, (3) non-randomized trials, (4) quantitative descriptive studies, and (5) mixed methods studies. Upon determining study category, quality ratings are provided according to subsequent criteria. Two independent reviewers appraised 39 articles using the MMAT. After individually assessing the articles, reviewers reconciled ratings and a third author resolved conflicts through discussion. Duplicate studies were removed after the review and a total of 32 quality appraised studies remained.

Data extraction was completed by two independent reviewers and reconciled, with a third author for potential disagreements. A table was synthesized for the final study characteristics (refer to Appendix 3). The table consisted of the following information: first author, title, country, study design, duration, participants, type data, outcome, and quality/design score. The quality/design score was obtained through the process of quality assessment using the MMAT. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

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The study selection and screening process is outlined in Fig. 1 . A total of 32 studies are included in this systematic review. Of all the articles, 3 were qualitative studies, 5 were quantitative non randomized studies, 4 were quantitative descriptive studies, and 3 were mixed methods studies. The remaining 17 studies were quantitative randomized controlled trials. Of the 32 articles, Netherlands, Singapore, Japan and Australia contributed one study per country. 2 studies were from Taiwan and the remaining studies were from the USA. All included studies passed the initial screening criteria and was rated based on the MMAT. Among the 32 articles that were quality appraised 12 were rated an overall score of five, 16 were rated four, and 4 were rated three. None of the included studies were rated two or one stars.

Data and results were extracted from the literature and synthesized into a study characteristics table (refer to Appendix 3). The main outcomes that met the inclusion and exclusion criteria and contributed to improved well-being were compared. The analysis of mindfulness interventions and their effectiveness resulted in the identification of five themes.

1. Basic mindfulness refers to an intervention involving focused attention to a sensory experience such as rhythmic breathing and attention monitoring. 2. MBSR refers to an 8-week Mindfulness-Based Stress Reduction program encompassing techniques for guided mindfulness using meditation, and a focus on opening up to a moment-by-moment experience. 3. L2B refers to the Learn 2 Breath program dedicated to the acronym BREATHE. The core themes established include: having a body awareness, understanding one's thoughts, working with one's feelings, the integration of thoughts, feelings and sensations, decreasing harmful self-judging thoughts, and making a conscious effort into integrating mindfulness practises in daily life. 4. MBCT refers to mindfulness-based cognitive therapy which focuses on acceptance and awareness of thoughts and emotions. 5. Unique Methods included different techniques that did not fit into established programs and were used for assessing positive emotions, feelings of meaning, and purpose.

The five qualitative mindfulness themes that contributed to improving well-being were found to be interrelated and often had similar targets and outcomes.

Strong correlations were determined between the implementation of mindfulness interventions and overall mental health. Students that practiced mindfulness reported lower levels of stress, depression, and sleep issues, leading to an overall increase in the well-being of young adults [5] . Mindfulness interventions also decreased the frequency of experiencing negative emotions and enhanced attention to personal emotions [6] . Heightened awareness resulted in better regulation of their emotions so that students could experience greater equanimity and less reactivity [6] . In addition, students practicing mindfulness reported significantly less burnout compared to the control group [7] .

Anxiety is a common symptom observed in young adults experiencing constantly changing environments, particularly in individuals learning how to adapt to varying work flows and lifestyles [8] . The effect of different mindfulness-based interventions (MBI) were assessed to observe its effect on improving anxiety in college students. A study by Bamber et al. [9] concluded that MBI with a focus on relationships/loving-kindness and insightful meditations were shown to have no significant effect on anxiety. However, students who participated in brief focused breathing exercises reported increased performances in difficult arithmetic tests, due to a reduction in anxiety after the exercises [10]. When students participated in MBI, a reduction of anxiety symptoms was reported [11, 12] . These studies indicate that MBI with a focus on breathing can reduce anxiety levels in college students.

MBI has also been shown to influence academic performance in students. Bellinger et al. [13] determined an indirect benefit of mindfulness in improving math performance by reducing anxiety. Mindfulness interventions before quizzes improved performance, but short five minutes bi-weekly sessions of mindfulness had no significant effect on students' exam scores [14] . These findings suggest that brief mindfulness can be beneficial for enhancing knowledge retention of lecture content in the short term. Lin & Mai [15] also found significant short-term improvements in academic performance. In the long-term, however, several studies found no significant improvements in academic performance after mindfulness interventions [12, 16] . In contrast, Cavanagh et al. [17] found that mindfulness interventions resulted in better final exam performance in conjunction with cognitive reappraisal (which involves mentally reframing views of boredom, frustration, and anxiety to change their meaning and the emotions they arouse). Though mindfulness may not have directly impacted exam performance, mindfulness could increase student awareness of personal feelings (such as boredom) for recognition and proactively apply cognitive reappraisal techniques to reframe them.

Mindfulness interventions played a role in enhancing metacognitive ability. The implementation of meditation exercises were shown to enhance introspective accuracy including visceral sensations, affective states, and ongoing performance on tasks. Meditation exercises focused on breathing enhanced metacognitive ability for memory, but there were no significant improvements in perceptual decisions [18] . Although many papers reported that mindfulness led to more positive emotional experiences, interventions did not produce significantly higher levels of emotional intelligence [7] .

In addition, interventions reduce mind wandering on tasks requiring sustained attention which may be beneficial for college students, as most schoolwork requires sustained attention [19] . Students also report being more "on-task" after mindfulness training [19] . Yamada and Victor [16] found that 81% of students self-reported positive effects of mindful awareness practices on their learning, indicating that students enjoy this practice.

In terms of memory, a short-term 15-minute mindfulness practice had no impact on working memory tasks [21] . Working memory refers to the ability to temporarily store and use the information to solve problems. A week-long mindfulness intervention did not increase working memory or decrease mind wandering, yet it prevented stress-related working memory impairments, which suggests short-term mindfulness has indirect benefits to working memory [22] . However, a more extended approach where focused attention meditation was practiced for two weeks showed significant improvements in memory [18] .

This systematic review provides an examination of the current literature regarding the impact of mindfulness interventions to improve well-being along with academic success. Generally, practicing mindfulness improved mental health and had positive psychological results, but the outcomes for academic performance were mixed.

Five different intervention strategies will be discussed in depth for potential implementation.

Considering the COVID-19 worldwide pandemic, it is important that these strategies can be applied successfully in virtual settings as well.

Many studies included in this review incorporated generic mindfulness techniques rather than following specific programs. Common exercises included in sessions are rhythmic breathing, meditation, attention monitoring, and acceptance. Baird et al. [18] identified basic mindfulness as meditation exercises requiring focused attention to some aspect of sensory experience. Wei Lin et al. [15] introduced basic sitting meditation to students to stabilize the mind and rhythmic breathing exercises to increase focus and self awareness. Rhythmic breathing involves focusing the attention on one's nostrils, and the act of breathing [15] . Results from this study showed that those who completed these basic MM were able to sustain their focus, improving learning. Mindfulness questionnaires also indicated that students felt an increased amount of mindfulness 9 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 27, 2021. ;  after completing the meditations, compared to the control group [15] . Other forms of basic mindfulness focus on attention monitoring and acceptance. Attention monitoring trains students to focus on breathing and somatic sensations, thoughts and emotions, and meta-awareness of cognitive, emotional and physical events [19] . Acceptance trains students to have non-judgemental attitudes towards these thoughts and sensations [19] . Many other studies were conducted in which students were trained in these MM practices as an anchor for attention, so that they could sustain their attention on sensations and emotions without being distracted [18] . Generally, implementations of these techniques enhanced students' ability to sustain attention which improved short-term academic and task performance [6, 12, 23, 24, 25] .

A common mindfulness intervention that is effective for improving college student well-being is the Mindfulness-Based Stress Reduction (MBSR) program lasting 8 weeks [7] . MBSR is a form of guided meditation to improve mindfulness. Jain et al. [26] examined the effect of the MBSR program on full-time medical students, nursing graduate students, and undergraduate students enrolled in a premedical program. The study compared mindfulness meditation (MM) and somatic relaxation (SR) given in the MBSR format focusing on the improvement of students' well-being. The MM intervention consisted of guided body scan meditation, where one gradually focuses their attention to each part of the body, sitting meditation, Hatha yoga (which consists of stretching the body through gentle movements), walking meditation, and loving-kindness meditation, where one expresses feelings of love and kindness to oneself and others [26] . The SR intervention consisted of muscle relaxation and breathing exercises. The results indicate that MM interventions given in the MBSR format enhance positive mindsets and reduce ruminative and distractive thoughts associated with depressed moods, increasing cognitive ability [26] . Another study was conducted on medical students using the MM interventions stated in the previous study [5] . Medical students were given training in all of the interventions over 8 weeks. The MM interventions given over the MBSR program in this study were shown to improve psychological well-being, reduce state and trait anxiety, and increase empathy [5] .

A derivative of MBSR was used to assess the effect of mindfulness practices on student learning in a course. The study consisted of a 10-minute sitting meditation routine led by an instructor at the beginning of each class [16] . Students in the intervention group reported a better cognitive experience by participating in the 10-minute mindfulness activity before class [16] . However, the final exam scores showed no significant improvement for the course between the intervention group and the control group without training [16] . Studies were also conducted comparing MBSR and E. Easwaran's 1978/1991 eight-point program (EPP) on improving mindfulness in college students. No significant differences were found between MBSR and EPP, and both were found to reduce stress [26, 27] . An 8-week long MBSR program with 7 weekly two-hour classes was set up for students [28] . The group which participated in the MBSR program showed significant improvements on the Mindfulness Attention and Awareness scale, and improvements 10 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 27, 2021. ;  with working memory capacity and visual threshold [16] . Sankoh [7] created a modified 8-week MBSR course for medical and premedical students with reduced class times to match the students schedules. Students were also encouraged to use the Headspace mobile app to practice mindfulness during their own time [7] . Little significance was found in mindfulness scores between students who participated in the modified MBSR compared to those who did not [7] . Those who did the course reported feeling smaller impacts of burn out, compared to those who did not do the course [7] . Articles in this review show strong evidence that MBSR programs can be an effective method for students to increase mindfulness and reduce stress [7] . They can also be modified to fit the lifestyles of students, and still have a significant improvement on well-being.

Mindfulness meditation can be taught in the form of Mindfulness-based cognitive therapy (MBCT). The goal of Mindfulness meditation (MM) was to promote awareness and acceptance of thoughts and emotions rather than the suppression of them [22] . Participants were taught to focus on breathing and take note of any mind wandering that occurs, promoting acceptance, rather than judge oneself for it [22] . Focusing the mind on simple breathing was encouraged [22] . Results of this study indicated that MM did not improve mind wandering, or working memory, but did have a strong significance in improving mindfulness in students [22] .

A popular intervention revolved around specific focused-attention meditation and breathing called Learning to BREATHE (L2B) [17] . In these techniques, students were told to choose a specific task (such as breathing), recognize when the brain becomes distracted from the task, be able to shift attention back to breathing, and have strong cognitive understanding of distractors [14] . Core practises included a body scan, maintaining mindfulness of thoughts, emotions and movements [29] . These breathing exercises were successful when performed right before small quizzes, but not in long-term effects on scores [29] . Additionally, the goals for the program involved gradually building up inner strength and empowerment through the commonly used structure of 8 sessions [29] . The program hoped to enhance the students' skills in regulating emotions, improve management of stressful situations, and improve learning processes [29] . As a result, this program was successful for stress reduction and management, self-regulation, and improvements towards a healthier lifestyle (e.g. more exercise and less alcohol consumption) [30] . Finally, participants in the program demonstrated high gains in emotion regulation above all [29] . Overall, L2B is an effective method for long term emotional/stress regulation.

Some papers presented unique mindfulness interventions that were applicable to their specific research aims without using pre-existing programs. Instead of using general mindfulness techniques, studies used cognitive reappraisal interventions, positive psychology interventions 11 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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(PPIs), and somatic psychoeducation [17, 31, 32] . Through cognitive reappraisal interventions, there was a focus on normalizing emotions in a college classroom setting [17] . Mindful ways of approaching emotional experiences were introduced, rather than techniques for reappraisal [14] . PPIs were used for students taking a positive psychology course [31] . One study researched the effects of a somatic psychoeducation experimental course on well-being by organizing activities designed to increase somatic awareness and trust between other people [32].

One way that mindfulness interventions can be introduced into the Felicity App is through breathing reminders. Users can choose to receive reminders to breathe and focus their attention on body sensations and present emotions. Notifications to 'remember to breathe' could appear hourly or whenever the user decides upon routinely. The pop up reminder could also include a link to more detailed meditation practices or an image with a quick exercise. One limitation is that pop up notifications are easily dismissible.

Another feature that can be incorporated is modified versions of pre-existing mindfulness programs, like MBSR (8 weeks) and L2B (6 weeks). The programs introduce different mindfulness related topics weekly so the same topics could be presented in the virtual application as simplified exercises. Guidance on activities could be given through an audio recording or through written instructions where students will be completing tasks in an individual setting. Activities that could potentially be included are body scan meditation, hatha yoga, walking meditation, and loving-kindness meditation. Each activity is useful for targeting symptoms influencing the well-being of students.

Literature with varying study designs were included for this systematic review, resulting in high heterogeneity precluding statistical analysis. Incorporating qualitative, quantitative, and mixed method studies enabled a qualitative analysis of present data. Self reports and surveys were analyzed to gain more insight into how mindfulness interventions impact individual experiences and overall well-being.

This systematic review included articles with participants from North America, Europe, Asia, or Australia but excluded other countries, which may lead to potential bias in data. Of the 26 studies from North America, all studies were conducted in the US. 4 studies were conducted in Eastern and Southern countries of Asia, specifically Taiwan, Singapore and Japan. Only 1 study was conducted in Europe. Studies only from one country may be a poor representation of the region as a whole. In addition, only studies written in the English language were included in this systematic review which can narrow the scope of literature findings. Due to the heterogeneity of study design and findings, further research (including additional quality assessment and 12 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 27, 2021. ; https://doi.org/10.1101/2021.04.24.21256035 doi: medRxiv preprint statistical analysis) is required to determine the efficacy of virtual mindfulness interventions within well-being.

In this systematic review, the effect of different mindfulness-based interventions on the well-being of college students was studied. The symptoms to be targeted by mindfulness-based interventions were investigated, as well as the procedures and outcomes of the interventions. Specific criteria were used to include articles relevant to the application of implementing mindfulness-based interventions on the Felicity App. Screening criteria was developed and quality appraisal was used to ensure only relevant articles were included in the review. However, more research should be done on whether mindfulness practices can improve academic performance and their impact on cognition.

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[10] de Bruin EI, Meppelink R, Bögels SM. Mindfulness in higher education: Awareness and 13 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 27, 2021. ; https://doi.org/10.1101/2021.04.24.21256035 doi: medRxiv preprint attention in university students increase during and after participation in a mindfulness curriculum course. Mindfulness (N Y) . 2015;6(5):1137-42.

[11] Potek R. Mindfulness as a school-based prevention program and its effect on adolescent stress, anxiety and emotion regulation; 2011 (Unpublished).

[12] Stein SD. Impact of a 3-minute mindfulness-based exercise on anxiety and academic performance; 2016 (Unpublished).

[ 14 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 27, 2021. 15 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 27, 2021. ; https://doi.org/10.1101/2021.04.24.21256035 doi: medRxiv preprint

This systematic review was funded in part by a grant from The Duke of Edinburgh's International Award through the P2P program and in partnership with the federal government of Canada.

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

JX devised and supervised the project and secured funding acquisition. AP and LN established the screening criteria and performed the searches. HJ and AL carried out the quality assessment and data extraction. AP, LN, HJ and AL equally contributed in data analysis and manuscript write up. JX and HJ refined and approved the manuscript.

16 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 27, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 27, 2021. ; MBIs have a large and significant effect in decreasing college students' anxiety. Despite researchers' emphasis on relationship/loving kindness and insightful meditations, these aspects of mindfulness meditation interventions did not influence MBI's effect on anxiety.

1/**** 18 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 27, 2021. 

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) Performance on the sustained attention to response task (SART) and two working memory tasks (operation span, delayed recognition with distractors)

Mindfulness training (MT) participants had higher task accurate and self reported being more "on task" after 7 week training. MT didn't significantly benefit operation span task accuracy and doesn't improve working memory.

2/**** 20 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 27, 2021. ;

The effects of mindfulness-bas ed interventions for health and social care undergraduate students -a systematic review of the literature USA Quantitative randomized controlled trial; systematic review to identify effects of mindfulness-based interventions to health and social care undergraduate studies; studies with medicine, nursing and psychology students that met inclusion criteria (n = 11) Five Facet Mindfulness Questionnaire and the General Health Questionnaire Benefits reported in participants' stress, mood and mindfulness levels, anxiety, well-being, self compassion and coping abilities. Further research with long-term follow-up is required to definitively conclude that mindfulness is an appropriate intervention to mentally prepare health and social care undergraduate students for their future careers.

2/*** Oman Meditation lowers stress and supports forgiveness among college students: a randomized controlled trial USA Quantitative randomized controlled trial; two 8 week 90 min per week training program; college undergraduates in mindfulness-based stress reduction group n = 15), Easwaran's Eight-Point Program n = 14), or wait-list control (n = 15).

No treatment differences between MBSR and EPP. Treated patients had significant benefits for stress and forgiveness. Evidence shows that meditation-based stress management practises reduce stress + enhance forgiveness among college students 2/****

Effects of mindfulness-bas ed stress reduction on medical and premedical students. The effect of breathing exercises was greater on the high math anxiety group.

Effect of L-theanine showed greater calmness on the high math anxiety group but with low significance 4/**** 21 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The interventions did not result in better same-day learning, but students performed better on the final exam items from intervention days, particularly the cognitive reappraisal day.

2/*****

Mindfulness meditation for college students: A study of its utility and promotion of its practice post treatment USA Quantitative randomized controlled trial; mindfulness-based stress reduction program for 4 weeks that taught two forms of mindfulness-based stress management techniques; college students from major university (n = 123)

Mindfulness training seemed to help student interpreters become more aware of and regulate their own emotions and attention, experience greater equanimity and less reactivity, and become kinder toward themselves, including when they were interpreting. Some participants, however, may have been over-attributing to mindfulness the progress they felt they 2/***** 22 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted April 27, 2021. ;  were making in their interpreting classes. Mindfulness training seemed to help student interpreters become more aware of and regulate their own emotions and attention, experience greater equanimity and less reactivity, and become kinder toward themselves, including when they were interpreting. Subjects who practiced mindfulness developed slightly better conceptual models (their quality was 8.16% higher) and they did it faster (they were 46.67% more productive) than the control group.

3/**** 23 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) Exploring daily affective changes in university students with a mindful positive reappraisal intervention: A daily diary randomized controlled trial.

Franco, C., Manas, I., Cangas, A., & The application of mindfulness with students of secondary school:

26 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted April 27, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 There is no performance, there is just this moment: The role of mindfulness instruction in promoting health and well-being among students at a highly-ranked university in the United States Mind-body skills training to improve distress tolerance in medical students: A pilot study 31 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted April 27, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 

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