The transition into tertiary or post-secondary education (university or college) is a significant milestone in the lives of young adults. While many cope well, a large proportion of students experience high levels of stress, anxiety and depression. Ramón-Arbués et al., (2020) reported a moderate prevalence of depression and anxiety, and reported that 34.5% of college students experienced significant stress. An Australian report indicated that 83.2% of students in tertiary education in Australia felt stressed, 79% were anxious, 66% reported high psychological distress and greater than 50% experienced sleep disturbance (Rickwood et al., 2016). More concerning is the dramatic increase in mental health disorders and the limited availability of supports to meet service demands with this population (Auerbach et al., 2018).

A recent study of over 600,000 college students in the United States, reported rates of depression, anxiety, suicidal ideation and attempts doubled between 2007 and 2018, with the steepest increase occurring in the period from 2014 to 2018 (Duffy et al., 2019). Moreover, there is some emerging evidence that the COVID-19 pandemic resulted in further increases in anxiety and depression in college students compared to a similar stage of the previous academic year (Huckins et al., 2020).

The existence of mental health issues in students studying health-related programs at university or college is supported by recent studies; however, much of the research has focused on the mental health of medical students. Medical students are at a high risk of experiencing burnout given the academic pressure, perfectionist standards and demanding nature of medical practice (Nechita et al., 2014; Ray & Joseph, 2010; Ribeiro et al., 2017). While there are several studies that investigate the mental health of medical students, there is less research that has investigated the depression, stress and anxiety levels of students in other health professions such as, occupational therapy, physiotherapy, speech pathology, social work and psychology. Given the similarities between medical training and allied health training programs, the psychological problems experienced by students in all these courses is expected to be commensurate. Ribeiro et al., (2017) suggested that students’ resilience may be compromised, particularly in the transition to clinical placements in health-related courses. Moreover, students in these courses are often at an age where stress-related disorders are more common (Regehr et al., 2013).

The introduction of mindfulness-based programs is one approach used to assist in the management of student stress, anxiety and depression in this population. Mindfulness-based interventions have shown to be successful in cognitive and behavioural approaches for students experiencing depression, stress and anxiety (Hofmann & Gómez, 2017). Mindfulness refers to the state of bringing non-judgmental awareness to the present moment and is described as having two components: (1) self-regulation of attention and (2) orientating an individual to the present moment with curiosity, openness and acceptance (Bishop et al., 2004; Hofmann et al., 2010). Two common mindfulness-based interventions include mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT) (Kabat-Zinn, 1982; Teasdale et al., 2000). Mindfulness-based stress reduction is an 8-week treatment program with regular 45 min per day of meditation practice. In contrast, MBCT incorporates mindfulness training with cognitive therapy but consists of the same program duration and associated home practice.

Numerous studies have reported the effectiveness of mindfulness programs in reducing the levels of stress and depression in university students (Regehr et al., 2013; Reid, 2013). Given the effectiveness of mindfulness programs with this population, there have been calls for the inclusion of mindfulness in the training of all health professionals to help address the increased psychological problems often experienced by this population with preliminary research supporting its effectiveness (Ruff & Mackenzie, 2009). A recent pilot study was completed with undergraduate speech pathology students in Perth, Western Australia. Students participated in wellness discussions, mindfulness activities and created a wellness plan (Lewis et al., 2019). Participants reported having new strategies to manage procrastination and stress, and welcomed the opportunity to discuss mental health management in a safe and supportive environment (Lewis et al., 2019).

Despite calls to include mindfulness programs in the training of health students to help them manage depression, anxiety and stress, to date, there has been no review of the literature on how to best achieve including and delivering this training to health students. This sco** review examined the effectiveness of mindfulness-based interventions for health students delivered at tertiary or post-secondary institutions (university or college) and how these programs were implemented with this population. The review will explore intervention characteristics, recruitment and retention and the most effective strategies in implementing mindfulness-based interventions to improve student well-being. This research will enhance understanding of the impact of mindfulness practice for health students and the most effective principles and strategies in implementing these practices to improve student well-being.

Methods

A sco** review was conducted following a systematic process for conducting sco** reviews as outlined by Arksey & O'Malley, (2005) and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Sco** Reviews (PRISMA-ScR) (Tricco et al., 2018). Given the large heterogeneity of study designs and quality of the studies investigating the effectiveness of mindfulness-based interventions with health students, a sco** review was deemed more appropriate to summarise the current literature than a systematic review (Arksey & O'Malley, 2005). The five-step process by Arksey and O’Malley (2005) was used to provide structure to the process and improve the transparency of the findings. The five steps were: (1) identifying the research question; (2) identifying the relevant studies; (3) study selection; and (4) charting the data; (5) collating, summarizing and reporting the results.

Eligibility and Study Selection

Title and abstract screening were doubled-screened by the research team after duplicates were removed for eligibility. Full-text articles were obtained for articles that met eligibility criteria based on their title and abstract. Papers were included if the participants in the study were enrolled in a tertiary or higher education institution in a health-related course (university or college, graduate or undergraduate) and completed a mindfulness-based intervention with three or more sessions within the program. The health-related programs included in the search were medicine, nursing, pharmacy and allied health courses. The mindfulness-based intervention could be provided in any modality and was not restricted to being conducted on a university campus. Only studies that included one or more outcome measures for anxiety, stress and/or depression were included, and inclusion of a mindfulness-awareness measure was optional. Other disciplines, non-students, exercise based or non-intervention studies were excluded. All team members completed a review of the full-text articles that met the eligibility criteria. Any disagreements throughout the study selection process were resolved through discussion and consensus.

Search Strategy

A systematic and comprehensive search of three databases (PsychINFO, Medline and Embase) was conducted. Each database thesaurus (subject headings and related terms) was checked to generate additional search terms. The search strategy was limited to articles published from 2009 to 2020, written in English and available online through university databases. Articles were limited from 2009 to 2020 given the significant proliferation of mindfulness-based intervention studies over the past 10 years (Goldberg et al., 2017). A free-text search was then conducted within the databases for literature published in the previous 12 months. The reference lists of all articles were searched for additional studies. All citations were exported to a reference manager. See supplementary materials for a full search strategy example.

Data Collection

A descriptive-analytical methodology was utilized to chart data (Arksey & O'Malley, 2005). The authors jointly developed a data chart extraction table to extract data. Data were extracted independently by the authors and results were discussed and continuously updated through an iterative process. The following data were extracted and collated: (1) author/s, year, journal, country of origin, paper type; (2) summary; (3) participant: demographics, enrollment (undergraduate/postgraduate), course discipline, cohort (e.g. first-year, final-year); (4) study design; (5) intervention style (face-to-face, web-based, self-guided, home practice); (6) intervention design (dosage and duration); (7) recruitment and retention, (8) intervention approach; (9) outcome measures (e.g. depression, anxiety, stress, understanding of mindfulness); (10) study findings; and (11) determination of inclusion with rationale.

To confirm data extraction reliability between reviewers, the research team independently extracted data from the final 24 papers. Disagreement was resolved through discussion and consensus by all the authors.

Results

Study Selection

The initial search from the databases yielded 2809 articles, of which 156 were duplicates, Title screening from the remaining 2653 articles resulted in 2537 articles being excluded. From these 116 articles, abstract screening excluded a further 51 articles. The remaining 65 papers progressed to full-text review. Of these papers, 41 papers were excluded after the full-text review. A total of 24 papers met eligibility criteria and were included for data extraction, collation, summarising and reporting. Figure 1 represents the process undertaken for article selection.

Fig. 1
figure 1

Flow diagram for study selection

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Study Location and Participants

A summary of the results is outlined in Table 1. The results from this review found that the majority of studies were from the United States (n = 12) and Europe (n = 5), and the remaining were from Australia and Asia (n = 6) and Brazil (n = 1). Most studies were conducted with students from medicine (n = 10), followed by combined health sciences (n = 5), nursing (n = 3), psychology (n = 3), speech pathology (n = 1), pharmacy (n = 1) and social work (n = 1). The ‘combined health science’ category included participants completing mixed medical and dental courses, nursing, occupational therapy, physical therapy or physiotherapy, counselling, education and sociology. Participants in the studies were at various levels of study including undergraduate (n = 7) and postgraduate (n = 6). Four studies included both undergraduate and postgraduate students, with six studies not reporting the level of study for their participants. Most studies (n = 21) had a higher ratio of female to male, with four studies having excluded male participants.

Table 1 Population characteristics
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Study Design

Eleven of the 24 studies included were single cohort studies, seven randomized controlled trials and six control studies.

Recruitment

Many of the studies experienced difficulty recruiting and had lower than expected participant numbers (Barbosa et al., 2013; Dyrbye et al., 2017; Greeson et al., 2015; Kang et al., 2009). Small sample sizes were reported as a limitation in several studies (Barbosa et al., 2013; Kuhlmann et al., 2016; Phang et al., 2015; Rimes & Wingrove, 2011; Song & Lindquist, 2015; Spadaro & Hunker, 2016; Warnecke et al., 2011) or they reported that the study did not have adequate power (Beck et al., 2017). Various methods of recruitment were utilized. Ten of studies reported invitation emails, information sessions, social media invitations and flyers to recruit participants (Barbosa et al., 2013; Beck et al., 2017; Burgstahler & Stenson, 2019; Call et al., 2014; Erogul et al., 2014; Greeson et al., 2015; Newsome et al., 2012; Phang et al., 2015; Spadaro & Hunker, 2016; Warnecke et al., 2011). Four of the studies approached participants as part of the unit or course (Burgstahler & Stenson, 2019; Dyrbye et al., 2017; Hassed et al., 2009; Neto et al., 2020). Participants in one study were given a $50 voucher to participate (de Vibe et al, 2013) or a nominal amount (Kang et al, 2009). The remaining studies did not report recruitment methodology. Timetabling and time restraints were reported as contributing factors for poor recruitment in one study (Barbosa et al., 2013). A summary of the recruitment strategies is outlined in Table 2.

Table 2 Recruitment and retention
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Retention

Two studies provided course credit to participants (Newsome et al., 2012; Shearer et al., 2016), while three papers incorporated mindfulness as part of the curriculum to improve retention rates (Call et al., 2014; Hassed et al., 2009). The study that included the largest sample of participants (n = 288) used a financial reward at the final data collection point (de Vibe et al., 2013). This study reported the highest retention rate when participants were followed up after 6 years (de Vibe et al., 2013). One study raffled for a voucher to participants and due to low response rates, provided a 20 Euro voucher for all follow-up assessments (Kuhlmann et al., 2016). Another study informed participants that learning the techniques to cope with stress and improve mindful practice would assist in their professional careers, which attracted a sample of 135 participants (Phang et al., 2016). A summary of the retention strategies is outlined in Table 2.

Intervention

Intervention programs were delivered in a variety of formats. A summary of the intervention programs is outlined in Table 3. The length of program varied from three weeks to a full semester, with ten studies running programs for 8-week duration. Twenty of the programs were delivered with at least some face-to-face sessions, and 14 of these included self-guided programs which followed initial face-to-face sessions where participants were taught the principles of the practice of mindfulness.

Table 3 Intervention characteristics
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Mindfulness-Based Stress Reduction (MBSR), adapted MBSR or Mindfulness-Based Stillness Meditation (MBSM) were the most common interventions used, utilized in 11 of the interventions (Barbosa et al., 2013; Burgstahler & Stenson, 2019; de Vibe et al., 2013; Erogul et al., 2014; Neto et al., 2020; Phang et al., 2015; Roulston et al., 2018; Shearer et al., 2016; Spadaro & Hunker, 2016; van Dijk et al., 2017; Warnecke et al., 2011). Two studies (Phang et al., 2016; Rimes & Wingrove, 2011) incorporated mindfulness-based cognitive therapy (MBCT) while the remainder of the studies evaluated other interventions including yoga and body scanning (Call et al., 2014; Lemay et al., 2019; Newsome et al., 2012), combined mindfulness and cognitive behavioral therapy (Hassed et al., 2009; Kuhlmann et al., 2016), mindfulness meditation (Beck et al., 2017; Kang et al., 2009; Song & Lindquist, 2015) and stress and resilience training (Dyrbye et al., 2017; Greeson et al., 2015).

Outcome Measures

Only two studies (Hassed et al., 2009; Song & Lindquist, 2015) found a statistically significant decrease in measures of depression following mindfulness intervention, compared to seven papers that found no statistically significant differences (Kang et al., 2009; Kuhlmann et al., 2016; Neto et al., 2020; Rimes & Wingrove, 2011; Spadaro & Hunker, 2016; van Dijk et al., 2017; Warnecke et al., 2011). Nine studies found a statistically significant decrease in anxiety (Barbosa et al., 2013; Burgstahler & Stenson, 2019; Call et al., 2014; Kang et al., 2009; Lemay et al., 2019; Shearer et al., 2016; Song & Lindquist, 2015; van Dijk et al., 2017; Warnecke et al., 2011), and four studies found no statistically significant reduction in anxiety following mindfulness intervention (Hassed et al., 2009; Kuhlmann et al., 2016; Rimes & Wingrove, 2011; Spadaro & Hunker, 2016). Fifteen studies found a statistically significant decrease in stress (Burgstahler & Stenson, 2019; Call et al., 2014; de Vibe et al., 2013; Dyrbye et al., 2017; Erogul et al., 2014; Greeson et al., 2015; Kang et al., 2009; Lemay et al., 2019; Newsome et al., 2012; Phang et al., 2016; Phang et al., 2015; Roulston et al., 2018; Song & Lindquist, 2015; Spadaro & Hunker, 2016; Warnecke et al., 2011), while one paper reported a statistically significant reduction in psychological distress (van Dijk et al., 2017). Only one study reported no statistically significant decrease in stress (Kuhlmann et al., 2016) following mindfulness-based therapy. One study reported a statistically significant decrease for female participants only (Dyrbye et al., 2017), while another found statistically significant differences in stress levels for first-year psychology students only (Rimes & Wingrove, 2011).

Discussion

This sco** review identified 24 papers that used mindfulness-based intervention (MBI) approaches with students enrolled in tertiary or higher education institutions in a health-related course. These papers included results from nine countries, a wide range of health related courses, students at different levels of education, and reported varying recruitment and retention strategies, interventions and outcomes. The most common MBI approaches were based on mindfulness-based stress reduction (MBSR) principles (Kabat-Zinn, 1982). Various methods of delivery were utilized, including short courses and online delivery. Virtual instruction was considered a viable method of delivery when face-to-face sessions may not be available. Findings from this review suggest that despite differing intervention approaches and delivery, most had a positive effect on student’s mental health well-being.

These findings should be interpreted with some caution as weaknesses were identified in a few studies. While mindfulness interventions with health students seem to work, a number of studies reported that recruitment was voluntary, thus by nature, the participants were more likely to be more motivated to engage in mindfulness interventions. Moreover, this could also suggest that the students who would benefit the most from mindfulness-based interventions, may not have the motivation to participate, thus the impact of these interventions may be diluted. It was also noted in some of the studies that participants in most need of MBI were more likely to drop out of the program, reinforcing the potential benefits of MBI for people with significant mental health issues.

Study Location and Participants

All participants within the studies selected were enrolled in health professional university courses. A broad range of health professions were represented in the included studies, however, medical students comprised the largest group compared to any other single profession. Therefore, caution should be used in interpreting the results when generalizing to students from other health professions where factors contributing to increased anxiety, stress and depression or motivation to engage with mindfulness programs may differ.

Several of the studies included in this review noted an imbalance in the gender of the cohort of students recruited with some authors expressing concerns about this being a potential limitation of generalizing to the greater population. Gender-specific effects of mindfulness have been examined in some studies with a reported increased effect for female participants in reducing stress (de Vibe et al., 2013). Given many health professions have a greater proportion of females, with up to 97.5% of speech pathologists and 90.6% of occupational therapists being female, this may be less of an issue for these professions compared to professions with a higher proportion of males, such as medicine with 44% females and physiotherapy with 65.6% females (Australian Health Practitioner Regulation Agency, 2020; Speech Pathology Australia, 2015).

It is also important to note that 45% of studies included in this review were conducted in institutions within the United States (US). It is unclear as to whether students from this region may respond differently to mindfulness programs compared to students enrolled in other countries, or whether the educational system within the US may contribute to different levels of stress, anxiety or depression than in other parts of the world.

Engagement

Recruitment, retention and engagement were reported as a challenge in a number of the studies, and many studies included smaller sample sizes than planned. Despite multiple methods of recruitment, including emails, information sessions, social media and flyers, no method was identified as a superior method of recruitment. This highlights a broader challenge with this demographic in how to engage health students to prioritize activities to improve mental health given the high time demands and reluctance to seek proactive assistance.

Participants were recruited through voluntary channels, as an extracurricular activity, embedded within course content, or provided as an online or take-home task. This strategy may have resulted in the recruitment of participants who demonstrated higher motivation to undertake mindfulness training or, as authors of one study suggested, were more primed to focus on personal difficulties (Carpenter et al., 2019). There remains a lack of evidence to ascertain whether mindfulness programs offered as an extracurricular activity are more effective than embedded within health curricula.

From this review, the most successful strategy to encourage participation and engagement is embedding mindfulness-based intervention within the curriculum; however, this presents numerable challenges for educators and course designers in the presence of an already saturated curriculum in these courses. Another strategy that demonstrated some utility was highlighting to students the importance of mindfulness-based techniques and strategies to assist not only during tertiary studies but as lifelong skills as a future health professional (Newsome et al., 2012).

Recruitment and retention were commonly noted as challenges across a number of studies. While traditional extrinsic strategies such as gifts or prizes seemed to improve recruitment and retention of participants appeared to have an impact, linking the importance of managing the participant’s own mental health to the impact of delivering high-quality care to their clients and patients was also an effective strategy. Interestingly, the experience of the person who provides the MBI may be an important factor, but this was not reviewed exclusively, and a wide variety of people delivered the MBIs within this study.

Limitations and Future Research

Analysis of the methodological quality of the articles was not completed as this is a not key component of sco** reviews. Further, the heterogeneous populations, intervention designs and delivery methods, as well as a lack of standardized outcome measures, limited the ability to conduct a systematic and meta-analysis of the results. While these are common features of sco** reviews, the findings outlined in this paper should be interpreted with consideration of these limitations. Finally, the variability in study designs needs to be acknowledged, which made it difficult to draw definitive conclusions about the outcomes.

Given the majority of the research to date with health students has been completed with medical students, a large gap in research remains for investigating the impact of MBI with students from other health professions, particularly the allied health professions. While there appears to be more research completed with females than males, no gender effects have been reported. Future research could investigate the influence of gender on the effectiveness and use of MBI in this population. More rigorous randomized control trials and a systematic review over the history of mindfulness interventions is recommended to investigate effective engagement and retention in more detail, and comparing mode of delivery of MBI for allied health students.