Volume 27, Issue 2 (Spring 2021)                   Intern Med Today 2021, 27(2): 246-263 | Back to browse issues page

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Sabetfar N, Meschi F, Hosseinzade Taghvaei M. The Effectiveness of Mindfulness-based Group Therapy on Perceived Stress, Emotional Cognitive Regulation, and Self-care Behaviors in Patients With Hypertension. Intern Med Today 2021; 27 (2) :246-263
URL: http://imtj.gmu.ac.ir/article-1-3613-en.html
1- Department of Psychology, Faculty of Psychology, UAE Branch, Islamic Azad University, Dubai, United Arab Emirates.
2- Department of Psychology, Faculty of Psychology, Karaj Branch, Islamic Azad University, Karaj, Iran. , fa_meschi@yahoo.com
3- Department of Psychology, Faculty of Psychology, Karaj Branch, Islamic Azad University, Karaj, Iran.
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1. Introduction

High blood pressure is the most critical risk factor in predicting death and premature death in the world [1]. Studies show that the prevalence of hypertension among people over 25 years in Iran is 29.9%, which is in line with other countries, including Nepal, China, and the United States. Hypertension is also associated with overweight and obesity, high triglycerides, diabetes, and cardiovascular disease [2]. In the past, the evaluation of health and disease was based only on physical factors, but today the definition of health is much broader, and in addition to the desired physical condition, mental factors (such as experiences, behaviors, and psychosocial status) are also considered [3]. The doctors have shown that patients with high blood pressure often suffer from psychological stress. Stress, anger, and aggression seem to trigger physiological responses in the sympathetic nervous system and stimulate the secretion of stress hormones, thereby increasing blood pressure [4]. 
Perceived stress is one of the influential factors in patients with hypertension. Stress is a severe threat that causes mental or physical illness [5]. According to Lazarus and Folkman, stress is a special relationship between people and events. Some people evaluate the events more than their abilities and consider them threats to their health [6]. A person’s interpretation and evaluation of events lead to stress. Stress is a neurological and physiological response, and high levels of depression and anxiety increase the degree of vulnerability to stress [6]. 
In addition to stress, people with high blood pressure have shown significant psychological and mental disorders. Montan’s study showed that mental disorders are essential in the onset or exacerbation of hypertensive symptoms in patients [7]. Evidence also shows that difficulty in regulating emotions, such as anger and anxiety, plays a role in developing physical problems such as cardiovascular diseases and hypertension [7]. The ability to express emotion is called emotion regulation. Gross suggests that emotion regulation refers to the process that affects emotions, experiences, and expressions and helps in a person’s awareness to understand, accept, and control provocative behaviors to achieve personal and situational goals [8, 9]. The newest and most comprehensive models of cognitive-emotional regulation belong to Gross [10], who proposed a model of the emotion regulation process. Evaluation of emotional symptoms occurs before an emotion is fully experienced. These emotional symptoms can be evaluated from different aspects, and after this evaluation, they may be triggered in various physiological, behavioral, and experimental responses [11]. 
Among the health determinants, self-care behaviors are an important way to prevent disease, especially chronic diseases. Because of the patient’s urgent need for self-care to control this disease, patient participation and cooperation in self-care are ways to improve blood pressure control [12]. Self-care includes prevention, maintenance of health, and disease treatment by the person, including a healthy lifestyle, treatment of diseases, and disease management [13]. Although the benefits of self-care in improving blood pressure are evident, most people do not follow self-care behaviors [14]. For high blood pressure, self-care guidelines such as weight loss, physical activity, smoking cessation, and consumption of sodium-free foods can play an essential role in regulating and controlling blood pressure [15].
In recent decades, evidence has shown that mindfulness interventions significantly impact people’s psychological health. Cognitive mindfulness therapy as a treatment option can increase patients’ physical health, hope, and optimism [16]. Mindfulness is one of the interventions studied in stress reduction [17], defined by Kabat-Zinn [18] as moment-to-moment and non-judgmental awareness. According to a particular method, i.e., presence at the moment, mindfulness can reduce the symptoms and consequences after the disease, increase the effectiveness of treatment and help prevent disease recurrence [19, 20]. Studies have shown the effectiveness of mindfulness interventions in improving and controlling chronic diseases, including cardiovascular disease [21], hypertension [22], diabetes [23], and obesity [24]. Studies also show that mindfulness-based therapy with a variety of health consequences such as stress reduction [22, 25], Stress [22, 25-27], anxiety and depression [26], and fatigue is associated with cancer [28] and pain [27]. 
Other research studies have shown that mindfulness improves mood, and its short training courses are associated with reducing depression and increasing patients’ psychological well-being [29]. Mindfulness also increases awareness of emotions and effectively improves regulating emotions [29, 30]. As a result, it improves other aspects of physical and psychosocial functioning [30] and promotes adherence to treatment [31]. Now, the main question of the research is whether group therapy based on mindfulness is effective on perceived stress, emotional, cognitive regulation, and self-care behaviors of patients with hypertension. 

2. Materials and Methods 

The study design is quasi-experimental conducted on two groups with a pre-test, post-test, follow-up, and the control group. The study population included all patients with hypertension in Kish Island, Iran, referred to one of the medical centers there for treatment from March to June 2020. In experimental and quasi-experimental studies, a sample size of at least 15 people per group has been proposed [32]. So, the study sample consisted of 32 qualified volunteers who met the inclusion criteria and were selected by the purposive sampling method. Then, the samples were randomly divided into 2 groups of 16 people each (1 experimental group and 1 control group). The experimental group underwent mindfulness-based group therapy, but the control group did not receive any intervention. The inclusion criteria included having primary blood pressure based on the patient’s medical record, not having diabetes, lacking complications of heart attack, stroke, or psychiatric disorders, not using psychiatric drugs before or during the study, not participating in counseling and psychotherapy sessions since 6 months before the intervention, and lacking physical disabilities. They should not have secondary hypertension caused by other diseases such as alcohol poisoning, atherosclerosis, adrenal tumors, or taking birth control pills. The exclusion criteria were more than one session absence from the intervention program, participation in another training or treatment workshop, and unwillingness to continue cooperation. 
Implementation method
First, pre-test data were collected, and then the experimental group underwent mindfulness-based therapy. At this stage, the control group did not receive any experimental intervention, but to comply with ethical principles, a 2-hour session was held for these patients, in which only the disease was described. After 8 sessions, a post-test was performed for both groups, and after 2 months, a follow-up was performed. Because of the spread of coronavirus, the first session and the collection of pre-test information were performed in person. The second and third sessions were conducted online, the fourth session was conducted in person, the fifth to seventh sessions were conducted online, and the final session and post-test and follow-up information were collected in person. Online meetings were held using Adobe Connect software. After data collection, data analysis was performed using repeated-measures analysis of variance (ANOVA) in SPSS v. 22. The significance level of the tests was considered 0.05. 
Study tools
Cohen Perceived Stress Questionnaire (1983) 
Cohen et al. developed the perceived stress questionnaire in 1983. In this study, a 10-item version of this questionnaire was used. The questionnaire is scored on a 5-point Likert scale. The lowest total score is 0, and the highest 40. A higher score indicates more perceived stress. Cohen et al. [31] conducted a study to examine the psychometric properties of this scale. The results show good reliability with the Cronbach α of 0.78 on this scale. In a study in Iran, Khalili et al. showed that the Persian version of this questionnaire has good validity and reliability and reported a Cronbach α coefficient of 0.90 [33]. 

Garnfsky Cognitive Emotional Regulation Questionnaire (2001)
Garnovsky et al. developed the emotional cognitive regulation questionnaire in 2001 to identify cognitive coping strategies after experiencing adverse events or situations. It has 36 items. The answers to this questionnaire are scored on a 5-point scale. The authors of this questionnaire calculated its validity through the Cronbach α for positive strategies of 0.91, negative strategies of 0.87, and the whole questionnaire of 0.93 [34].
Self-care Behaviors Questionnaire for Patients With Hypertension (2014) 
Han et al. designed and psychoanalyzed the self-care behaviors questionnaire for patients with hypertension in 2014. The Persian version consists of 20 questions scored on a 4-point Likert scale. The results of the exploratory factor analysis of Ghani Gheshlagh, Prized et al. In 1397 showed the four factors of diet (items 3, 4, 5, 7, 9, 10, and 11), diet (1, 14, 15, 16, and 20), food labeling (2 and 8) and disease management (12, 13, 17, 18, and 19) Explain 51.39% of the total variance of self-care variables. Also, the results of the confirmatory factor analysis of this questionnaire indicated its good fit. The internal consistency of the complete tools based on the Cronbach α coefficient was 0.865 [12]. 
Therapeutic sessions of group therapy based on mindfulness
According to Segal et al., mindfulness-based therapy is based on cognitive therapy with mindfulness. In the current study, this approach was implemented in 8 groups within 90-minute counseling sessions. During these sessions, the rules and regulations of the session were expressed, help patients, set goals positively, and assignments. Also, various techniques were used during the sessions to suit the situation (Table 1).


3. Results

According to Table 2, the mean and standard deviation of the scores of dependent variables in the experimental group significantly changed. Also, these changes remained in the follow-up phase, while there are no significant changes in the control group. To evaluate the significance of these changes, repeated-measures ANOVA was used. Before performing the test, the assumptions of this test were examined. The results of the Kolmogorov-Smirnov test showed that the distribution of three variables of perceived stress, emotional self-regulation, and self-care was normal (P>0.05). Also, the results of Levene’s test showed that the distribution of dependent variables at the levels of groups (intervening variable) was homogeneous and similar (P>0.05). According to the results and non-significance variables, the assumption of homogeneity of variances has been established, and there is no problem in performing the analysis of variance test mixed with repeated measures. 

Table 3 presents that the interaction effect of time group on positive perceived stress (Eta squared=0.534, P=0.001, F= 24.749), negative perceived stress (ETA squared=0.254, P=0.001, F=7.665), positive emotion (Eta squared=0.518, P=0.001, F=24.194), negative emotion (Eta squared=0.580, P=0.001) F=31.030), diet (Eta squared=0.182, P=0.011, F=5.017), medication diet (Eta squared=0.225, P=0.003, F=6.527) and disease management (Eta squared=0.150, P=0.026, F=3.984) have a significant effect at the level of 0.05. The results also showed that at the level of 0.05, mindfulness-based group therapy had no significant effect on the food label variable (Eta squared=0.070, P=0.195, F=1.696). The mean scores of positively perceived stress, negatively perceived stress, positive emotion, negative emotion, medication regimen, diet and disease management in the mindfulness-based treatment group increased compared to the control group.  


4. Discussion

This study aimed to evaluate the effectiveness of cognitive mindfulness group therapy on perceived stress, emotional, cognitive regulation, and self-care behaviors of patients with hypertension. The results showed that the scores between the experimental and control groups in the perceived stress variables were positive and negative; Emotional self-regulation and the components of the diet, medication, and disease management there is a significant difference (P<0.05). The results showed that the scores between the experimental and control groups in the perceived stress variables were positive and negative; Emotional self-regulation and there is a significant difference between the components of diet, medication, and disease management. But no significant difference was observed between the food label scores between the two groups (P>0.05). This finding indicates the effectiveness of mindfulness-based group therapy on perceived stress, which is consistent with the research of Marquez et al. [25]. They examined the effect of mindfulness meditation on lowering blood pressure and stress in patients with hypertension. Also, in Solano Lopez, a review study entitled “The Effectiveness of Mindfulness-based Stress Reduction Program” showed the program’s effectiveness in reducing stress in people with hypertension [22]. Tulloh et al. in a study entitled “Stress Reduction Mindfulness Program”, showed that this method is effective in reducing stress [36]. Oberg et al. concluded that this program positively affects lowering blood pressure and improving quality of life [37]. Khosravi and Ghorbani concluded that this method affects reducing perceived stress [38]. 
In mindfulness-based interventions, according to the particular method, i.e., presence at the moment, acceptance, desensitization, increase of awareness, and observation without judgment are emphasized, which can reduce the symptoms and consequences of stress. These qualities can reduce the symptoms and consequences of stress. In mindfulness, seven techniques are used: non-judging, patience, the beginner’s mind (initiating mental state), trust, not struggling, accepting, and releasing (let it pass). All of these techniques are effective in combating stress [16]. In addition to the techniques used, because the treatment was group therapy, patients talked about each other’s experiences, the disease, and self-care methods. So the experience of group therapy has led to a reduction in stress in patients. 
This finding showed that cognitive-minded group therapy affected emotional self-regulation. Altin et al. found that this program has a positive effect on emotion regulation [30]. Ponti et al. in a study entitled “The Benefits of Mindfulness in Reducing Blood Pressure and Stress and Negative Emotion in Patients With Hypertension”, concluded that this program positively reduces negative emotions [39]. Campbell et al. in a study entitled “The Effect of Stress-Based Mindfulness on Attention, Rumination and Blood Pressure in Women With Cancer”, concluded that the program helps reduce stress and rumination in patients [40]. This finding can be explained by the fact that mindfulness is a method that, combined with self-relaxation and specific mental orientations towards an experience, encourages awareness of the present, without prejudice, and accordingly reduces conflict in thoughts and feelings [41]. Mindfulness reflections usually involve focusing on the present or using breathing as an anchor and reliance, allowing disturbing thoughts to pass through the mind without prejudice [42]. As a result of this technique, the individual is taught to substitute more appropriate responses to emotional distress and reduce conditioned responses. Individuals learn to separate experiences from themselves in the conscious mind and accept them as a transient and subjective state for change. 
Cognitive mindfulness focuses on behavioral cognition prevention skills such as identifying high-risk situations, coping skills training, and mindful meditation. Mindfulness exercises teach subjects to observe emotional, physical, and cognitive states without involuntary reaction. Using cognitive techniques, including non-judgmental techniques, people are taught to accept their thoughts and feelings without judgment. This method prevents negative thoughts and causes changes in the person’s patterns, beliefs, and attitudes about her thoughts. 
This finding indicates the effectiveness of mindfulness-based group therapy on self-care among patients with hypertension, which is in line with the findings of Marquez et al. [25]. Bloom et al. in a study entitled “Blood Pressure Analysis of Stress Reduction Using Mindfulness Meditation and Yoga”, concluded that these techniques were helpful in lowering blood pressure in patients. The mindfulness-based therapies, addressing physical and psychological dimensions, have high effectiveness for some clinical interventions and physical ailments. For example, paying attention to thought processes was one of the most critical changes in the mindfulness approach that allowed many patients to engage with the healing process and increase self-management and self-care by adhering to medication, diet, and disease management.

5. Conclusion 

Cognitive mindfulness group therapy can positively affect patients with hypertension in terms of perceived stress and their emotion regulation on the one hand and self-care behaviors on the other hand. The cognitive mind showed that it is important to pay attention to the thought process. Also, awareness of thoughts, emotions, and feelings can lead to greater acceptance and commitment to mental events and less experimental withdrawal. It also creates a state of greater compassion and flexibility. The mindfulness approach creates a more significant gap between motivation and reaction and demonstrates the subsequent ability to have a broader range of skillful approaches to situations. People with high metacognitive awareness can avoid illnesses such as stress, depression, and negative thinking patterns. 
One of the limitations of the present study is the lack of cooperation of some patients to participate in intervention sessions. The present study showed that mindfulness-based therapy is effective on perceived stress, emotional and cognitive regulation, and self-care of patients with hypertension, so the results of this study can be used to design and conduct seminars and workshops to teach mind techniques. 

Ethical Considerations

Compliance with ethical guidelines

This study was approved by the Ethics Committee of theIslamic Azad University, UAE Branch (Code: IR.SBMU.RETECH.REC.1399.590). All ethical principles are considered in this article. The participants were informed about the purpose of the research and its implementation stages. They were also assured about the confidentiality of their information and were free to leave the study whenever they wished, and if desired, the research results would be available to them.


This article was extracted from Nima Sabetfar’s PhD. dissertation of the first author at the Department of Psychology, Faculty of Psychology, UAE Branch, Islamic Azad University, Dubai, United Arab Emirates.

Authors' contributions

All authors equally contributed to preparing this article.

Conflicts of interest

The authors declared no conflict of interest.


We want to thank the Vice Chancellor for Research, the management of Kish Medical Centers, and all the medical staff of Kish Medical Centers who helped us conduct this research.


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Type of Study: Original | Subject: Mental Health
Received: 2020/11/14 | Accepted: 2021/04/7 | Published: 2021/03/21

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