evaluation of a seven-week web-based happiness training to … · 2015-03-17 · improve...

Hindawi Publishing CorporationEvidence-Based Complementary and Alternative MedicineVolume !"#$, Article ID %&%'($, #) pageshttp://dx.doi.org/#".##((/!"#$/%&%'($

Research ArticleEvaluation of a Seven-Week Web-Based Happiness Training toImprove Psychological Well-Being, Reduce Stress, and EnhanceMindfulness and Flourishing: A Randomized ControlledOccupational Health Study

T. Feicht,1,2 M. Wittmann,3 G. Jose,4 A. Mock,5 E. von Hirschhausen,5 and T. Esch1,2,6,7

! Division of Integrative Health Promotion, Faculty of Social Work and Health, Coburg University of Applied Sciences,Friedrich-Streib-Str. ", #$%&' Coburg, Germany

"Department Healthy University, Coburg University of Applied Sciences, Friedrich-Streib-Str. ", #$%&' Coburg, Germany( Institute for Frontier Areas in Psychology and Mental Health, Wilhelmstr. (a, )#'#* Freiburg, Germany%Division of Social Work, Faculty of Social Work and Health, Coburg University of Applied Sciences,Friedrich-Streib-Str. ", #$%&' Coburg, Germany

& Foundation Humor Hil+ Heilen, Dolivostraße #, $%"#( Darmstadt, Germany$Neuroscience Research Institute, State University of New York, College atOld Westbury, ""( Store Hill Rd, Old Westbury, NY !!&$*, USA

)Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Harvard Medical School,CO-!('#, "nd Floor, O,ce "'%A, ((' Brookline Avenue, Boston, MA '""!&, USA

Correspondence should be addressed to T. Esch; [email protected]

Received !)May !"#$; Revised $ November !"#$; Accepted #) November !"#$

Academic Editor: Stefanie Joos

Copyright © !"#$ T. Feicht et al.*is is an open access article distributed under the Creative Commons Attribution License, whichpermits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background. As distress in society increases, including work environments, individual capacities to compete with stress have to bestrengthened.Objective.We examined the impact of a web-based happiness training on psychological and physiological parameters,by self-report and objective means, in an occupational health setting. Methods. Randomized controlled trial with #)& employees.Participants were divided into intervention (happiness training) and control groups (waiting list).*e intervention consisted of aseven-week online training. Questionnaires were administered before, a+er, and four weeks a+er training.*e following scales wereincluded: VAS (happiness and satisfaction), WHO-( Well-being Index, Stress Warning Signals, Freiburg Mindfulness Inventory,Recovery Experience Questionnaire, and Flourishing Scale. Subgroup samples for saliva cortisol and alpha-amylase determinationswere taken, indicating stress, and Attention Network Testing for e,ects on attention regulation. Results. Happiness (! = 0.000; " =0.93), satisfaction (! = 0.000; " = 1.17), and quality of life (! = 0.000; " = 1.06) improved; perceived stress was reduced (! = 0.003;" = 0.64); mindfulness (! = 0.006; " = 0.62), -ourishing (! = 0.002; " = 0.63), and recovery experience (! = 0.030; " = 0.42) alsoincreased signi.cantly. No signi.cant di,erences in the Attention Network Tests and saliva results occurred (intergroup), exceptfor one saliva value. Conclusions. *e web-based training can be a useful tool for stabilizing health/psychological well-being andwork/life balance.

1. Introduction

!.!. Background. Psychology has long been primarily con-cernedwith perception of disorders and negative feelings, butcurrent scienti.c attention on happiness and the recognitionof positive mental states is at an “all-time” high [#, !]. Rea-sons for this development are rising levels of psychological

pressure and stress at work [$–(], which results in a reducedability to work due to psychological illnesses. *is develop-ment is noticeable in Germany. Compared to #''), the indexfor days of work missed due to illness increased by #!#.#%in !"## [%]. Since the last decade, researchers increasinglysearch for answers to the questions of what makes us feelgood and how to generate psychological stability and health

! Evidence-Based Complementary and Alternative Medicine

T/012 #: Short summary of the happiness trainings’ exercises.

Week #: basic principles(i) How do you feel? Check your state of mind.(ii) What hindered you in the past from being happy?(iii) Write a happiness-diary! Note three things that made you happy today.

Week !: joy of community(i) Get some body’s contact in a way that is comfortable for you.(ii) Identify your best friends and meet them this week.(iii) Write a thank-you letter.

Week $: joy of luck(i) Tell three people your wishes.(ii) Rejoice somebody by doing an unexpected favor.(iii) Let fortuity decide to do something new and give favorable opportunities a chance.

Week ): joy of pleasure(i) Eat a meal mindfully.(ii) Be mindful and capture happy moments with your camera.(iii) Challenge yourself with exercises/sports.

Week (: joy of -ow (i) Identify your strengths.(ii) Use them in a new way.

Week %: joy of bliss/beauty(i) Give little presents to make somebody happy.(ii) Write a gratitude-diary and note three things a day you are thankful for.(iii) Enjoy ten minutes of silence every day.

Week &: .nal(i) Detect your favorite happiness exercises.(ii) Be a happiness messenger and tell your favorite exercises to other people.(iii) Reward yourself for your happiness-work during the last week and give yourself a treat.

despite higher work-related demands. Studies showing a linkbetween happiness and vocational success make this a topicof interest for companies and the economy in general as wellas for individuals [&]. *e investigation of subjective well-being and happiness and the question of whether it is possibleto foster positive emotions through training are among theprime topics of happiness studies. Lyubomirsky et al. [3]found that a person’s happiness level is determined by $ fac-tors: a genetic set point for happiness, happiness-relevant cir-cumstances, and happiness-related activities and practices.Furthermore, the authors found that happiness-related activ-ities are themost powerful aspect of increasing and sustaininghappiness that is under individual control [&, 3]. Because thebrain, principally, never loses its ability to adapt ['], happiness(and, along with it, well-being) is learnable at almost everyage; yet activities for pursuing happiness need to be inten-tional and it takes e,ort to initiate, carry out, and maintainthem [3].

Positive interventions (i.e., positive psychology interven-tions) help to implement and increase happiness-relevantactivities.*ese are “treatment methods or intentional activ-ities aimed at cultivating positive feelings, positive behav-iors, or positive cognitions” [#"]. *e German happinesstraining of Dr. Eckart von Hirschhausen is such a pos-itive intervention: a &-week online training focusing onexercises for achieving a positive psychological state. Inaddition to an introductory week and a .nal week, there are( weeks with # happiness-relevant topic each (e.g., “joy ofluck” or “joy of pleasure”). Each week has $ exercises. *edetailed exercises for each week are shown in Table #. *etraining is voluntary, free of charge and can be accessed athttp://www.glueck-kommt-selten-allein.de.

In this studywe aimed to determine the impact of positiveinterventions in a concrete setting: we examined the e,ects ofonline happiness training on occupational health in a com-pany as assessed with questionnaires. We also investigated! other aspects. Because the training contains exercises onmindfulness and as studies have shown that mindfulnesstraining enhances the functioning of attention networks[##], we used the Attention Network Test to assess possiblee,ects on attention regulation. To determine if the trainingreduces stress at an objectively measurable level, we collectedsaliva samples to measure the stress hormones alpha-amylaseand cortisol [#!–#(].

In a !"##-!"#! pilot study, ##" students from CoburgUniversity underwent the happiness training program of Dr.Eckart von Hirschhausen in a randomized controlled trial(unpublished data). *e study had some limitations andthe hypothesized e,ects could not be a4rmed entirely, butthe data clearly showed the e,ectiveness of the training.Due to this outcome, we then decided to test the trainingagain with a more rigorous design, additional measures, and,particularly, in a di,erent setting (i.e., a more appropriate andpresumably a more change/training-sensitive target group),following expected stress and strain levels in employees in theGerman service sector. We were especially interested in thepossible e,ects of the training on participants experiencingincreasing psychological demands at work. Employees ofservice companies, especially those who provide telephoneservice, have been among the highest rates of inability toworkdue to burn-out, depression, or other psychological illnessesinGermany [#%]. For this reason,we chose to study employeesof an insurance company as our target group, because theyare o+en involved in telephone services and therefore have

Evidence-Based Complementary and Alternative Medicine $

the potential for improving their work/life balance using anintervention such the happiness training program.

In our paper we followed theCONSORT reporting guide-lines as far as possible and useful [#&].

!.". Primary Outcome/Hypotheses. *e primary objective ofthis exploratory study is the question whether the happinesstraining improves individual happiness and satisfaction withlife and relieves stress, and, as a consequence thereof, reducesstress-related symptoms in an occupational setting. Accord-ing to this, our primary outcome was psychosocial well-being, in connection with satisfaction (with life) and stresscoping.*e assumed e,ects would be relevant for the .eld ofoccupational health and medicine as a whole (e.g., primarycare and preventive medicine).

As a secondary objective we investigated how the trainingin-uencesmindfulness, recovery experience, and-ourishing.Furthermore, we tested whether there would be a decrease inobjectively measurable stress (measured by saliva samples) oran increase in attentional control (measured by the AttentionNetwork Test).

Taken together, there were ) aims of this study: -rst andas a primary objective, testing whether the happiness train-ing a,ected satisfaction and stress; second, determining thee,ects of the training on mindfulness, recovery experience,and -ourishing; third, investigating e,ects on objectivelymeasured variables related to stress and attention regulation;and fourth, determining if measurable correlations betweenthe analyzed variables exist.

2. Methods

".!. Ethics. *is study was conducted in !"#! and data wereanalyzed in !"#!-!"#$. Ethical approval was obtained fromthe Coburg University Institutional Review Board/EthicsCommittee in !"#!. In addition, the sta, council of theinsurance companywas o4cially informed about the study ina premeeting (!"#!). All participants gave informed consent.

".". Design. A randomized and controlled longitudinaldesign (! groups × $ times questionnaire/! subgroups × !times saliva andANT)was used for our study, with $ di,erenttime points (pre = $0, post = $1, followup () weeks later) =$2).*e intervention group underwent the happiness trainingpartly at work and partly at home (see also Section !.%.), andthe control group did not perform any of the online inter-vention activities or training and was passive on a waiting-list. A+er the end of the actual study, however, the controlgroup also did the training (cross-over design); yet, we didnot feed the cross-over into the analysis. *e reason forthe control group formally receiving the training a+er theactual study period (and nevertheless having this prospectivecross-over technically imbedded into the study design rightfrom the start, but no data analysis planned for this) was toguarantee all participants the same experience over the courseof the project.*is seemed to be appropriate, since it could beexpected that being allocated, for example, to the interventiongroup could produce somewhat “visible” behavior changes,

and so it rendered important to not produce a “loser” groupby random allocation to the control group. In fact, all par-ticipants could be sure that they would, .nally, get the sameexperience (happiness training), if they wanted.

*e questionnaires were completed at $0, $1, and $2. *esaliva samples and the ANT were only taken at $0 and $1.".(. Participants/Recruitment. *e sample consisted of #)&German-speaking, employed, adult volunteers from !depart-ments of a local insurance company with a total of )$$"employees. *e ! participating departments were chosen bythe company and we had no in-uence on this decision. Intotal about #"(" employees of the two departments werepossible participants due to the same hierarchy level. All ofthem had been invited for voluntary participation. #(% ofthem wanted to participate, were proved to be eligible, andwere thus included for randomization (Figure #).*e employ-ees of the ! participating departments were addressed andinformed about the study by their group leader. Inclusioncriteria were (#) regular access to the Internet at home (as theyperformed the training partly at home and partly at work),(!) no vacation of longer than # week during the surveyperiod, ($) no prior knowledge of or experience with theonline happiness training program. Every participant gaveinformed consent by formally subscribing to the training andthey all participated in an introductory class in which theyhad the opportunity to individually ask the project teamquestions.

".%. Randomization/Allocation. Concerning the classi.cationof the participants into intervention (IG) and control group(CG), we also considered local and structural conditions ofthe company. To avoid direct communication between IG andCG (e.g., when IG participants worked on instructions fromthe web-based training program at their desks, potentiallysitting next to each other) we di,erentiated between partici-pating sites. We had ! di,erent departments signing up. Onedepartment had open (cubicle) o4ces, the other one con-sisted of smaller o4ces with ! to % employees per room. Toprevent a direct in-uence between IG and CG, we strati.edfor groups, so that participants in one o4ce were in thesame group and not in “competing” groups. As not allemployees of each department decided to participate in thestudy, there were always some nonparticipants in the o4ces.Hence, randomization took place at an individual level, butvia formation of strata. Careful strati.cation procedures wereapplied in the process and prior to it, due to given practi-cal/structural constraints and statistical considerations. Yet,we established “virtual” study population compartments that,following department structures in the company, werederived from department a4liation of participants. An addi-tional goal of the illustrated processes was to carefully avoidhierarchic structures or uneven distribution of hierarchypositions and functions between intervention and controlgroups.

To summarize related randomization procedures, weperformed, within the strati.ed compartments established by

) Evidence-Based Complementary and Alternative Medicine

Questionnaire

Allocation

Followup(only questionnaire)

Posttest

Enrollment

Analysis/adherence to protocol

ANT Saliva

Pretest

QuestionnaireANT Saliva

Intervention group Control group

Employees of company (n = 4330)

Employees of participating departments (n = 1050)

Employees assessed for eligibility (n = 157) Excluded (n = 10)∙ Not meeting inclusion criteria (n = 9)∙ Other reasons (n = 1)

Included/randomized (n = 147)

(n = 85) (n = 62)(n = 21) (n = 21)(n = 23) (n = 22)

∙ n = 20∙ n = 1

∙ n = 17∙ n = 3

∙ n = 16∙ n = 1

∙ n = 18∙ n = 0

∙ n = 11∙ n = 4

∙ n = 19∙ n = 0

∙ n = 18∙ n = 3

∙ n = 15∙ n = 5

∙ n = 19∙ n = 2

∙ n = 21∙ n = 2

∙ n = 20∙ n = 1

∙ n = 21∙ n = 1

∙ Performedpretest (n = 77)

∙ Did not performpretest (n = 8)

∙ Performedpretest (n = 55)

∙ Did not performpretest (n = 7)

∙ Performedposttest (n = 72)

∙ Did not performposttest (n = 5)

∙ Performedn = 57)

∙ Did not perform

posttest (

posttest (n = 0)

∙ Performedfollow-up test

(n = 68)∙ Lost (n = 4)

∙ Performedfollow-up test

(n = 51)∙ Lost (n = 6)

∙ Analysed (n = 54)

∙ Excluded (n = 14)

∙ Analysed (n = 47)

∙ Excluded (n = 4)

F56782 #: Study and participant -owchart.

our statisticians, individual-level randomization, that is, allo-cation either towards IG or CG. Moreover, we made sure thatin case participants worked in smaller o4ces (size of, e.g., !people) and share direct o4ce space that both participantswere allocated to the same group. In this regard, our studycompartments (strata) were “physical.” *e reason for thesesomewhat complex measures was to keep spill-over e,ectsfrom IG to CG reasonably small.

In addition to the general study group allocation wehad ! subsamples: (#) from which saliva was collected and(!) who performed the Attention Network Test (ANT). *esubgroups were composed of participants from only one

department. We split all participants of this department andrandomly assigned them either to ANT or saliva testing;therefore, both subgroups were nonoverlapping.

Randomization procedures were performed by drawingpieces of paper (in lots) from a bag (an untransparent clothbag). All lots had the same look and were put into the bagand mixed thoroughly by one of the authors. *e bag wasprovided by the author and a noninvolved person wasdrawing the lots (blinded).

*e #)& participants were split into an intervention groupwith 3( participants and a control group with %! participants.*e di,erence in size between the groups is due to the

Evidence-Based Complementary and Alternative Medicine (

di,erent size of the open space o4ces in the company. Seethe -owchart for participation and drop-outs (Figure #).

".&. Instruments. Happiness and well-being are predomi-nantly subjective measures, which need to be de.ned fromthe subjective perspective of a person. For this reason, weused an online questionnaire consisting of di,erent sub-questionnaires to collect individuals’ self-reports for ourprimary/secondary objectives. For our primary objective weused the following.

At .rst, we used aVisual Analog Scale (VAS), which askedthe question “How happy are you right now?” and anotherasking “How satis.ed are you right now?” on a %-point ratingscale with a sad face on the le+ and a happy face on the right.

*e WHO-Five Well-being Index (WHO-() was derivedfrom a larger scale originally developed for a WHO projectstudying diabetes patients [#3]. WHO-( is a generallyaccepted quality of life/well-being screening instrument con-sisting of ( questions developed by theWorld Health Organi-zation (Psychiatric Research Unit, WHO Collaborating Cen-ter forMentalHealth, Frederiksborg, Denmark (German ver-sion from #''3) [#'–!!]. It covers positivemood (good spirits,relaxation), vitality (being active and waking up fresh andrested), and general interest (being interested in things) ona %-point Likert scale from " (not present) to ( (constantlypresent). In our study it was used to evaluate the generalquality of life and changes during the treatment. Exampleitems are “I woke up feeling fresh and rested” or “My dailylife has been .lled with things that interest me.”

*e Stress Warning Signals Scale (SWS) is a list of %#stress warning symptoms divided into muscular reactions,vegetative-endocrinological reactions, and cognitive, emo-tional, and behavioral reactions. Using the SWS, data on thesubjective stress experience of the participant was collected.*e rating follows a #"-point system (" = does not stress meat all, #" = stresses me a lot). *e scale was developed andvalidated by Esch et al. [!$, !)]. Example items for vegetative-endocrinological symptoms are “rapid heartbeat,” “chesttightness,” or “excessive sweating.”

For testing the impact and determining factors of thetraining (secondary objective), we used the following addi-tional questionnaires:

*e Freiburg Mindfulness Inventory (FMI) [!(] is a $"-item scale measuring mindfulness with a )-point Likert scale(# = rarely, ) = almost always). We used the #)-item shortversion.*e FMI is a useful, valid, and reliable questionnairefor measuring mindfulness. It is most suitable for use in gen-eralized contexts inwhich knowledge of the Buddhist conceptof mindfulness cannot be expected [!(]. *e #) items coverall formal aspects of mindfulness. Example items are “I amopen to the experience of the present moment” and “I amfriendly to myself/do not criticize myself when things gowrong.”

*e Recovery Experience Questionnaire (RECQ) [!%] isa valid and reliable questionnaire for use in assessing anindividual’s unwinding (i.e., relaxation or “wind-down”) andrecuperation processes. It measures the elements of “psycho-logical detachment from work,” “relaxation,” “mastery,” and

“control” on a #%-item scale with a (-point Likert scale (#=notat all, ( = very much). Example items are “In leisure timeI forget about work” and “In leisure time I decide my ownschedule.”

*e Flourishing Scale (FS) [!&] is an 3-item measure ofpsychosocial well-being and personal growth and develop-ment (i.e., -ourishing). A pilot study showed internal consis-tency and a moderately high reliability and validity [!&]. Weused a German version of this questionnaire (FS-D) trans-lated by Esch et al. [!$, !)]. Example items are “I lead apurposeful and meaningful life” and “I am engaged andinterested in my daily activities.”

In addition to the subjective reports of our participants,we wanted to know if there were any objective physiologicalor behavioral changes that could be detected. *erefore weanalyzed the e,ects of the happiness training on ! objectiveparameters. Two subsamples were built of participants fromone department.*e subgroup testing was only performed atpre- and posttest (no followup).

From one subsample (% = 45), we collected saliva at $di,erent times a day (directly a+er awakening, $" minuteslater, and at 3 pm) for analyzing saliva concentrations ofcortisol and alpha-amylase, which are indicators for theactivity of the ! stress axes in the body [#$–#(, !3]. It haslong been known that cortisol (i.e., elevated plasma levels thatare positively correlatedwith elevated saliva concentrations asindicators, e.g., for the hypothalamic-pituitary-adrenal stressaxis) can be an indicator of stress activity. Only recently,amylase received special attention in this regard, since itssaliva levels seem to correlate with sympathetic-adrenalmedullary system activation as an indicator for the sympa-thetic arm of the stress response [#$–#(, !3–$#], includingpositive correlations with norepinephrine/(nor) adrenalinelevels. However, since salivary alpha-amylase is not onlyin-uenced by (sympathetic) stress, with higher levels sug-gesting sympathetic activation, but also by salivary -ow rate(which ismore associatedwith parasympathetic activity), thisparameter is still under scrutiny. In any case, stress seemsto modulate alpha-amylase levels, as, for example, higherchronic stress seems to correlate with more deteriorated cor-tisol and amylase regulation [#(, !3, $", $#], or even attenuatedor -attened (but prolonged) response curves.Moreover, acutestress (also, acute stress responsiveness) in general correlateswith higher hormone levels. While still being speculative insome areas of interpretation, we nonetheless included thesesalivary stress parameters in our study to learn more abouta possible in-uence of a potentially stress-reducing web-based happiness training on the stress physiology.*erefore,participants of the saliva subgroup received % salivettes ($ ×pretest, $ × posttest) for collecting saliva, as well as detailedinformation on how to take the samples, before the pretest.

*e second objective instrument was the Attention Net-work Test (ANT; [$!]), which was conductedwithin the othersubsample (% = 42). Within a $"-minute testing session,the test assesses the functioning of $ attention networksin anatomical and functional terms: alerting, orienting,and executive control [$!, $$]. Reaction time measures fordi,erently cued and uncued stimulus conditions are used toquantify the processing e4ciency of these $ networks. Studies

% Evidence-Based Complementary and Alternative Medicine

T/012 !: Study population of analyzed data.

IG CG% () )&Female )# (&(.'%) !' (%#.&%)Male #$ (!).#%) #3 ($3.$%)Age (in years) $&.%# (SD &.&#() $%.&& (SD #".)!)Period of employment(in years) #(.3' (SD 3.($%) #).$% (SD '.#3)

have shown thatmindfulness training enhances the function-ing of these attention subsystems [##]. Because the happinesstraining contains exercises on mindfulness, we used this testto examine possible e,ects.

".$. Intervention. During the survey period, the participantsreceived an email reminder of the next survey point and theyhad the opportunity to contact the researchers via email fortechnical support. All participants took part voluntarily andneither gave nor received money to participate. *ere wasan introductory event for giving necessary information; atthe end of the study (% months a+er formal termination),participants received a thank-you present and were orientedabout preliminary results.

One day a+er the introductory event, the pretest was con-ducted: all participants .lled out the online-questionnairesand the ! subsamples gave the saliva or performed the ANT($0).*en, the happiness training started and ran for & weeksfor the intervention group. During this time, the IG receivedan email every week at work, explaining the current topic andthe $ exercises (time required: approximately #"–#( minutes,once a week). *e study of the documents pertaining tothe current topic was done during working hours and theperformance and documentation of the exercises took placeat home during free time.*e control group, which was on awaiting list, was a passive group and did not perform any ofthe online intervention activities or training.*e posttest ($1)was completed at the end of the training period, which was& weeks a+er $0. Again, the online questionnaire, the salivasamples, and the ANT were performed. *e last survey wasconducted )weeks a+er the end of the training (followup; $2).At this point only the online questionnairewas completed (nosaliva and ANT test).

Filling out the questionnaire and doing the ANT wasdone during working hours but the saliva samples werecollected at home because the times when they needed to betaken were not during working hours.

".). Data Analysis. In a .rst step, the group samples wereanalyzed according to drop-outs (Figure #). We analyzed thedata following adherence-to-protocol: those participantswhocompleted all tests were evaluated. *is means that for theanalyses of the questionnaire, all participants who .lled outthe questions at all $ time points ($0, $1, and $2) were included.*ere was a total drop-out rate (from randomization toanalyses) of $#.$%.Of these )% drop-outs (IG: $#, CG: #( drop-outs) #( participants decided not to enter the study (reasonsincluded illness, participants did not show up, or decided to

extend vacation during the survey) and did not even performthe .rst test. During the training ($0-$1) there were ( drop-outs (paradoxically there were ! drop-outs more at $0 thanat $1 in the CG. Reasons for this could be that participantsperformed the questionnaire at $0 but missed to press the“send” button at the end, so that the data was not transferred).Another #" drop-outs occurred during followup. Due toadherence-to-protocol procedure there were #3 drop-outs.

With the subgroups,all subjectswhoparticipated at $0 and$1 were included in the analysis. Saliva samples had a drop-out rate of #&.3% (% = 37; IG: #3/CG: #') and ANT had adrop-out rate of $(.&% (% = 27; IG: #%/CG: ##).

We compared between-group values (IG versus CG) for$0, $1, and $2, as well as within-group values for IG at $0-$1,$1-$2, and $"–$!. Because some of the data was not normallydistributed, we used nonparametric tests for the analyses.*e between-group e,ects were computed with the Mann-Whitney & test and the within-group e,ects were computedwith theWilcoxon test. With the nonparametric statistics therank order values are compared and statistical measures ofcentral tendency such as mean or median are used fordescriptive statistics. We computed e,ect sizes a+er Cohen’s" because we had a rather small sample. An e,ect size of ".!describes a small e,ect, ".( describes amedium e,ect, and ".3describes a large e,ect.

For the questionnaires, the sum of scores of each singlesubquestionnaire was computed and compared.

Saliva samples were analyzed at the laboratory of Pro-fessor Dr. Clemens Kirschbaum at the Technical Universityof Dresden. We collected data at time of awakening ($!0),$" minutes later ($!1), and at 3 pm ($!2) and then calculatedthe awakening response ($!1minus $!0), the morning activity(the mean of $!0 + $!1), the evening activity ($!2), andthe circadian rhythm amplitude (morning minus eveningactivity). We chose this calculation of the raw salivary datato be able to associate the measurements with other parts ofthe questionnaire.

*e ANT results were analyzed according to its standardprocedures.We computed the parameters of alertness, orient-ing, control, overall reaction time, and accuracy.

3. Results

(.!. Questionnaire. Descriptive statistics in the form ofmeansand standard deviations for both groups at all times anddi,erences in the outcome measures for IG versus CG arepresented in Table $. Within-group e,ects of the IG arepresented in Table ).

Table $ shows that mean levels of happiness, satisfaction,and quality of life increased during the training for the IG,and only slightly decreased during the follow-up period.*esame applies to the Stress Warning Signals—the means ofthe stress symptoms decreased numerically over the coursein sum and in all subcategories in the intervention group,whereas it increased in the control group. Also, the factorsmindfulness, recovery, and -ourishing increased numericallyfrom $0 to $1 in the IG, and their means at $2 were alwayssuperior or similar to $1. In the control group, all those

Evidence-Based Complementary and Alternative Medicine &

T/012$:Descriptiv

estatisticsa

ndbetween-grou

p-e,ectsof

theq

uestion

naire

.

Question

naire

$0$1

$2%=101

MSD

Mann-Whitney

U!

"M

SDMann-Whitney

U!

"M

SDMann-Whitney

U!

"Happiness

IG CG$.&

%$.3

##."

##.)

###%

).(

".)%#

".")

).(!

$.$3

#.#$

#.$)

%"$

".""

"""".'$

).$(

$.!$

#."#

#.$&

%3#

".""

"""".'!

Satisfaction

IG CG$.3

"$.%

3#."

"#.)

$#!%(.(

".'3"

".#"

).() $.#'

#.#$

#.#'

($!

".""

"""#.#&

).() $.$"

".'& #.$!

(33.(

".""

"""#.#"

Qualityo

flife

IG CG#$."'

#!.")

).#&

(.%#

##()

".)$!

".!!

#(.#(

#".!$

$.'"

(.)3

%!)

".""

"""#."

%#(.")

#".((

).$!

(.$)

%%).(

".""

"""".')

StressWarning

Sign

als-Sum

IG CG#3).3"

!"&.%

"'!.!&

##!.'#

##(&.(

".))

3".!!

#)&.!

3!#!.$

!3&.(&

##&.$!

3$'.(

".""$"

".%)

#$$."

'!#&.&)

&).%)

#!(.!

%&)#.(

".""

"""".3)

Muscular

IG CG!!.$"

!$.3$

#!.%3

#(."!

#!$)

".3#!

".##

#3.'#

!(.)$

##.')

#).)$

'$"

"."!#

".("

#3.(!

!$.$"

##.%#

#).'%

#"($.(

".#)!

".$%

Vegetativ

e-endo

crinologica

lIG CG

%".&3

%'.$"

$).!&

)".'#

##"'.(

".!&&

".!$

(".!!

&#.#&

!'.()

)$.''

'"".(

"."#!

".(&

)%.#'

&$.&!

!&.!!

)&.(!

3"3

".""!"

".&$

Cogn

itive

IG CG!&.3'

$$.$)

#(.3"

!".%$

##$$

".$()

".$"

!!.('

$$.#(

#%.!$

#'.(#

3&3

".""3"

".%"

!#.#$

$$.&!

#$.3#

!".)3

3"".(

".""#"

".&)

Emotional

IG CG$%.$"

)".&&

!".3)

!$.'#

##)#.(

".$3(

".!"

!%.'$

)!.""

!".%(

!$.3&

&(&

".""

"""".%'

!$.#$

)$.)$

#(.)$

!(.%&

%%#.(

".""

"""".'3

Behavioral

IG CG$&.()

)".$%

!!."3

!%.)3

#!)3

".33%

".#!

!3.%$

)".(3

#3."$

!%."'

'(".(

"."$"

".()

!).#$

)$.(&

#%.$'

!&.%3

&#)

".""

"""".33

Mindfulness

IG CG$(.3'

$).'3

%.() 3.$3

##$'.(

".$&&

".#!

$'.)$

$(.#&

%.)! &.)$

3%%

".""

%"".%!

$'.("

$(.#'

%.'& &.)$

3$(

".""$"

".%#

Recovery

experie

nce

IG CG)'.3(

(".&"

'."(

##.((

#!%%

".&&"

"."3

().(&

)&.3#

'.)&

#!.!'

3!).(

".""!"

".%$

($.3&

)'.)'

#".$"

#!.')

#""%.(

"."&)

".$3

Flou

rishing

IG CG)!.&)

)$.")

%.(#

3.%!

##!"

".$"'

".")

)%.#$

)$."%

&.#'

&.&#

'(#

"."$"

".)!

)(.&"

)$.3(

%.&$ 3.##

##").(

".!%!

".!(

" #<0.01,"" #<

0.001.

3 Evidence-Based Complementary and Alternative Medicine

T/012 ): Within-group e,ects (IG) of the questionnaire.

Within-group e,ects (IG)$"-$# $"–$! $#-$!! Wilcoxon

Z " ! WilcoxonZ " ! Wilcoxon

Z "Happiness ".""""" −3.63 ".&! ".""!" −3.05 ".(& ".$!' −0.98 ".#%Satisfaction ".""""" −3.64 ".&" ".""""" −3.52 ".&% ".&3$ −0.28 ".""Quality of life "."")" −2.88 ".(# "."#! −2.50 ".)% ".3'! −0.14 "."$Stress Warning Signals-Sum "."#! −2.51 ".)! ".""$" −3.00 ".%! ".)3& −0.70 ".#3

Muscular ".#() −1.43 ".!3 "."'( −1.67 ".$# ".'!! −0.10 "."$Vegetative-endocrinol. "."(3 −1.90 ".$$ "."!! −2.29 ".)3 ".(!# −0.64 ".#)Cognitive "."#' −2.35 ".$$ "."!! −2.29 ".)% ".3(% −0.19 ".#"Emotional ".""$" −2.95 ".)% ".""""" −3.58 ".3& ".)#" −0.82 ".!#Behavioral "."#' −2.35 ".)( ".""#" −3.47 ".&" ".!"( −1.27 ".!%

Mindfulness "."#" −2.57 ".(( "."#" −2.58 ".() ".3&$ −0.16 "."#Recovery experience "."#' −2.35 ".(# "."$& −2.09 ".)! ".&#3 −0.36 "."&Flourishing ".""!" −3.13 ".(" ".""&" −2.72 ".)( ".)%& −0.73 "."%"# < 0.01, ""# < 0.001.subjective parameters decreased or remained the same. Forall parameters the improvement in the IG from $0 was stillvisible at $2.(.!.!. Between-Group Analyses. Table $ also shows the resultsof the between-group analyses.*e e,ects were analyzedwiththe nonparametric Mann-Whitney & test (as data was notnormally distributed) and revealed signi.cant e,ects over thetest period. *e Mann-Whitney & test at $0 shows that atthe beginning the ! groups did not di,er. At $1, e,ects weredisclosed: satisfaction and quality of life di,ered signi.cantly,with e,ect sizes of># and! < 0.0001. Additionally, happiness(& = %"$, ! = 0.000, " = 0.93) and, among the stresswarnings signals, particularly emotional stress (& = 757,! = 0.000, " = 0.69) improved signi.cantly.*e training alsoshowed a strong positive e,ect onmindfulness (& = 866, ! =0.006," = 0.62), recovery experience (& = 824.5, ! = 0.002," = 0.63), and -ourishing (& = 951, ! = 0.03, " = 0.42).Even at $2, most variables (happiness, satisfaction, qualityof life, StressWarning Signals (except formuscular andmind-fulness)) showed signi.cant di,erences, with large e,ectsizes. Recovery experience, -ourishing, and muscular stressdid not show any signi.cant di,erences between groups attime point $2.(.!.". Within-Group Analyses. We used the nonparamet-ric Wilcoxon test for calculating within-group di,erences.Table ) gives an overview of results. *e table showsgood medium e,ects between $0 and $1, especially forhappiness (( = −3.63, ! = 0.000, and " =0.72) and satisfaction (( = −3.64, ! = 0.000, and" = 0.72), but also for quality of life (( = −2.88,! = 0.004, and " = 0.51). A similar outcome showsthe sum of the Stress Warning Signals (SWS), with ( =−2.51, ! = 0.012, and " = 0.42. In the categories of SWS,especially the emotional and behavioral symptoms decreased

(( = −2.95/−!.$(, ! = 0.003/"."#', and " = 0.46/0.45). *evariables of -ourishing (( = −3.13, ! = 0.002), mindfulness(( = −2.57, ! = 0.010), and recovery experience (( = −2.35,! = 0.019) showed a signi.cant di,erence, with mediume,ect sizes of " ≥ 0.5.(.". Subgroups

(.".!. Saliva. Saliva analyses for cortisol did not show any sig-ni.cant di,erences between groups. *e analyses for alpha-amylase showed ! e,ects—the awakening response betweengroups at $1was marginally signi.cantly di,erent (IG $0: &.#3,$1: −#!.)#; CG $0: ).'&, $1: #&.&&; & = 112; ! = 0.073; " = 0.6)and themorning activity within the IG between $0 and $1wassigni.cantly di,erent, with ! = 0.002 (( = −3.11; " = 0.83;IG $0: $(.%&; $1: ('.'().

For more results see Table (.

(.".". ANT. *e subsample of participants that performedthe Attention Network test had a high drop-out rate ($&.(%).At the end, only #% subjects of the IG and ## subjects of the CGcould be analyzed. Due to technical problems, some of thedata had to be excluded. Furthermore, the mean age di,eredsigni.cantly between IG (* = 39.6 years) and CG (* = 29.6years).*us the IG was on average #" years older than the CGin this subsample.

We found signi.cant changes from $0 to $1 within IG(Wilcoxon ( = −2.4, ! = 0.016) and CG (( = −2.8,! = 0.04) for executive control and the accuracy of responses(IG: ( = 2.6, ! < 0.008; CG: ( = 2.7, ! < 0.007),indicating a general learning e,ect, but no group di,erencesat $0 and $1.*e overall reaction time between $0 and $1 wassigni.cantly lower only for the CG (( = 2.9, ! = 0.003), andthe orienting e,ect was smaller at $1 than at $0 only forthe IG (( = 2.8, ! = 0.006). On closer examination ofthe descriptive statistics, however, no meaningful di,erence

Evidence-Based Complementary and Alternative Medicine '

T/012 (: Results of saliva samples.

Saliva% = 37 $0 $1 Between-group $1 Within-group (IG) $"-$#M SD M SD Mann-Whitney& ! " Wilcoxon( ! "

Alpha-Amylase (U/mL)Awakening response

IGCG

&.#3).'&

!3.")!#.(3

−#!.)##&.&&

((.$&)&.!! ##! "."&$ ".%" −#.## ".!%& ".)%

Morning activityIGCG

$(.%&$$.$(

!!.&'#'.(%

('.'(&3.&)

$%."$##&.'% #%# ".&%# ".!! −$.## ".""!" ".3$

Evening activityIGCG

#"'.3&#!#.%!

'".)%3!.33

##).)(#!%.3'

'!.')&).!) #)( ".)!' ".#( −".%$ ".(!3 "."(

Circadian rhythmamplitude

IGCG

−&).$"−33.!& 3#.#(3$.$%

−().)'−)3.#% &'.)3#"'."$ #%" ".&$3 "."& −#.!" ".!$# ".!(

Raw dataDirectly a+er awakening

IGCG

$!."3$".3%

!".((!".#!

%%.#%%'.3(

)&.)##"&.&!

$"minutes a+erawakening

IGCG

$'.!&$(.3$

$#.&3!).$%

($.&(3&.%!

)$.$3#$#.%3

At 3 pmIGCG

#"'.3&#!#.%!

'".)%3!.33

##).)(#!%.3'

'!')&).!)

Cortisol (nmol/L)Awakening response

IGCG

&.)3).$!

#".%3##.!$

%.3!).)&

##.('#$.!& #!% ".#&# ".#' −".!) ".3## "."%

Morning activityIGCG

$#.)&$".'(

'.%(#(.%"

!'.$&$#."(

#"."###.#' #(&.( ".%3! ".#% −".3( ".$'% ".!!

Evening activityIGCG

!.%&$.(#

#.3)$.3!

(.'().(%

#$.##&.(' #)& ".)%% ".#$ −"."" #.""" ".$%

Circadian rhythmamplitude

IGCG

!3.&'!&.)$

'.%"#(.&&

!$.)!!%.)'

#%.)$#$.$" #(( ".%!& ".!# −#.## ".!%& ".)#

Raw dataDirectly a+er awakening

IGCG

!&.&$!3.&'

&.&'#%.()

!(.'%!3.3!

##.%3#$.#'

$"minutes a+erawakening

IGCG

$(.!#$$.##

#$.(!#%.%!

$!.&3$$.!'

##.)(#!.3$

At 3 pmIGCG

!.%&$.(#

#.3)$.3!

(.'().(%

#$.##&.('"# < 0.01, ""# < 0.001.

#" Evidence-Based Complementary and Alternative Medicine

T/012 %: Results of Attention Network Test (ANT).$0 Between-group $1 Within-groupANT% = 27 $"-$# IG $"-$# CG

M SD Mann-Whitney& ! M SD Wilcoxon( ! Wilcoxon( !Alertness

IGCG

$'.!$(.!

#&. "!).! 3# ".&$" (".'

)3.%!!.##3.' #.(3 ".##( #.(% ".##'

OrientingIGCG

(#.)(%.(

!'.)$".' #"" ".(() $'.(

$&.&!#.(!#.$ −!.&& ".""% −#.(# ".#$"

Con-ictIGCG

#)".&#3%."

)".!#"!.3 #"% ".$&) ##'.$

#!3.(!!.'(3.& −!.)# "."#% −!.3( "."")

Reaction timeIGCG

%(3.&%&#."

%(.$&#.) '( ".&## %)#.$

%#'."(3.3((.( −#.3! "."%' −!.') ".""$

AccuracyIGCG

'(.''%.'

!.$!." #"' ".!'$ '&.)

'3.'#.%".& !.%( ".""3 !.& ".""&

T/012 &: Most signi.cant correlation coe4cients of IG (di,erences Δ between $#-$").Correlations IG Quality of life Happiness Satisfaction Mindfulness Alpha-Amylase Morning ActivityΔ$1 − $0 , , , , ,Happiness ".$&("" ".(&("" ".$"#"Satisfaction ".)"""" 0.575"" — ".))("" 0.850""SWS—emotional −".))%"" −".)&%"" −".)()"" −".$)%"SWS—sum −".)()"" −0.517"" −".)3)"" −".$$""Flourishing ".$$'" ".$'&"" ".)!)"" 0.600"""# < 0.05, ""# < 0.01.between IG and CG for the orienting e,ect was detectable.Table % gives an overview of results of the ANT.

(.(. Correlations. We conducted bivariate Spearman correla-tions of the intervention group di,erences between $1 and$0 and found some meaningful signi.cant associations. *emost important ones are listed in Table &. We found the mostsigni.cant correlations between satisfaction/happiness andquality of life (, = 0.400/, = 0.375)/mindfulness (, =0.445/, = 0.301). Additionally, the Stress Warning Signals(especially the emotional signals) correlated with quality oflife (, = −0.446), and happiness and satisfaction correlatedwith SWS (, = −0.517/, = −0.484).*e strongest correlationexisted between -ourishing and mindfulness (, = 0.600),and between satisfaction and the morning activity of alpha-amylase (, = 0.850).*e variables happiness and satisfactionalso correlated with each other (, = 0.575).4. Discussion

*e study outcomes emphasize the health promoting poten-tials of positive interventions—in this case, with reference

to occupational health and to the speci.c web-based hap-piness training of Dr. Eckart von Hirschhausen. All sur-veyed variables of health and/or individual well-being in theonline questionnaire showed signi.cant positive e,ects forthe intervention group (IG) between $1 and $0. *is e,ectbetween $1 and $0 was not detectable in the control group(CG). Moreover, at $1, the IG showed positive di,erences inall variables of primary concern as compared to the CG withremarkable e,ect sizes (e.g., " > 1 for satisfaction and qualityof life, with " > or = ".3 being a large e,ect).

*e intervention study was conducted during the moststressful period of the year in the company due to a veryhigh workload. *is means that the stress level at work wasconstantly high during our investigation, especially between$0 and $1. For this reason, we decided to calculate not onlybetween-group e,ects, but also within-group e,ects for theIG. Even failing to.nd a decline of health/well-being in the IGcould have been interpreted as a success. Most of the meansof the CG in the questionnaire show a decline from $0 to $1,which indicates the in-uence of the heavy workload phase.But despite the high “external” stress levels (i.e., circumstan-tial strain), an improvement in IGwas found, whichwasmostvisible in between-group analyses. As primary outcomes the

Evidence-Based Complementary and Alternative Medicine ##

subjective feeling of happiness and satisfaction increasedsigni.cantly, with large e,ect sizes. It could be argued that theVisual Analog Scale might not be the most appropriate tool,but as the gold standard of research on happiness states, itcovers an important .eld of the participants’ self-report [$),$(]. More solid evidence is provided by the WHO-( Ques-tionnaire; these ( questions are psychometrically valid toassess well-being state and/or to screen depressed mood [#'–!#, $%, $&]. Our signi.cant changes within theWHO-( can beinterpreted as amedically relevant outcome, which could alsobe relevant for primary care. *is result indicates that theonline training potentially makes the participants psycholog-ically healthier on ! levels: subjective and “medical” (withreference to depressive states).

Because mind and body are inseparable, it is not surpris-ing that the positive e,ects on subjective and mood-relatedexperience, as measured in our study, also had an impact on(or were correlated with) awareness of physiological levels.Being psychologically healthier andhappier is associatedwiththe awareness of physiological changes (e.g., as seen in thedecrease of stress warning symptoms). Especially emotionalreactions seem to become more stable a+er the happinesstraining. *is is hardly surprising, because these speci.cemotions are closely connected to overall happiness andwell-being. Furthermore, the cognitive and vegetative-endocrinological reactions especially improved.

In the ANT we could not .nd any signi.cant e,ect oftraining, which was probably due to the high drop-out rateand the small number of analyzable participants.*e big dif-ference in age (the IG was on average #" years older than theCG)might have in-uenced the results as well, although otherstudies have shown that there is no noteworthy di,erence inattentional capacities between subjects $" and )" years of age[$3]. *e ANT is one of the most valid and reliable instru-ments for testing attention regulation and has been usedin other studies successfully testing the positive e,ects ofmindfulness on attention [##, $']. In those studies the trainingof mindfulness was much more intensive. Our training usedexercises that fall within the scope of mindfulness, but thetraining itself might be insu4ciently mindfulness-based andtoo short to achieve signi.cant e,ects with the ANT. *ere-fore, training might need to be more mindfulness-based,more intense, and conducted over a longer period of timeto achieve ANT e,ects.

Regarding the saliva analyses, we tried to measurepossible objective e,ects of the ! stress axes in the body.*e samples were taken at $0 and $1, each time immediatelyat awakening, $" minutes a+er awakening, and at 3 pm.Due to the study design and the fact that the participantstook the saliva samples at home without supervision, it wasnot possible to precisely control the exact time when thesamples were taken; therefore, there might have beensome unknown variations in time of saliva collection. Wemeasured the concentration of cortisol as a parameter for thehypothalamic-pituitary-adrenocortical axis (HPA) [#)], andalpha-amylase as an indirect parameter of (nor) adrenalin,which is a parameter of the sympathetic-adrenal medullary(SAM) axis [#$]; see Section !.(. *e SAM is responsible forthe short-term stress reaction, the so-called .ght-or--ight

response [(, #!]. *is means that adrenalin increases fasterthan cortisol in a stress situation because it is a more directparameter of short-term stress. We found some signi.cante,ects, for example, with the amylase morning activity inthe intervention group (! = 0.002, " = 0.83). *e morningactivity is an established value and comprises of the sum ofthe “awakening value” and the “plus thirty value.” *e valueof morning activity increased in IG from $(.%&U/mL at $0to ('.'(U/mL at $1, possibly indicating a “healthy”—that is,physiological, well-functioning—regulation (see above),however, with lesser “alertness” (in absolute degrees) thanin CG. *is e,ect, compared with the overall tendency ofamylase values in IG to show less responsiveness in IG, forexample, decreased awakening response, in combinationwithmeasured outcomes of lower vegetative-endocrinologicalstress symptoms, could be interpreted, but with caution,as a sign that the participants of IG possibly started theirday being less alert or “stressed.” However, this is a morephysiological interpretation due to the knowledge of the !stress axes. *e evening e,ect did not show any signi.cantdi,erence or correlation.*emorning e,ect could thus, quitepossibly, be in-uenced—or “produced”—by better recovery(see next passage) in the evening/during the night andcould yet be lost during the day. Since these results andtheir theoretical association with a still vague knowledgein the .eld of amylase-cortisol-stress pathophysiology arerather speculative, they can only be seen and carefullybe interpreted as “piloting insights,” certainly warrantingfurther and more thorough investigation.

A crucial question is which determinants of the trainingled to the measured e,ects (secondary objective). Possibleanswers may be o,ered by results from the other question-naires: the study results show that the participants who weretrained (IG) felt an increase ofmindfulness between $0 and $1,more than the CG. Furthermore, an increase of the recoveryexperience can be seen between groups at $1. Itmay have beeneasier for the IG to “disconnect” or detach from work, relax,and assume control in leisure time to meet new challengeswhile they underwent the training. Perhaps they fell back intoold patterns a+er the end of the training, which could bethe reasonwhy therewas no comparable e,ect at $2. Likewise,the Flourishing Scale showed signi.cant di,erences withinthe IG between $0 and $1 and between $0 and $2, as wellas between groups at $1. Maybe those exercises act as a“door opener” for personal development and self-care ['] andpossibly the instructions were helpful or were the basis forthat progress.

*e dependent variables assessing psychological well-being correlate with each other as e,ects of the happinesstraining. Happiness and satisfaction were especially stronglycorrelated with quality of life and mindfulness. It seems asif the IG “learned to see and appreciate” the little thingsof everyday life, which draws attention to more positiveexperiences, which again couldmake individualsmore happyand thankful; however, this is rather speculative. *e sub-jectively positive experience also spread to physiologicalsigns: quality of life, happiness, and satisfaction were stronglycorrelated with the Stress Warning Signals—the happier theparticipants were, the fewer stress warning symptoms they

#! Evidence-Based Complementary and Alternative Medicine

described. *e strong correlation between mindfulness and-ourishing may describe a higher “spiritual level”; again,this is a rather speculative assumption. By undergoing thehappiness training, the participants perhaps got in touchwiththemselves and their surrounding andmay have realized thatthey can in-uence and control, at least to some extent, theirenvironment. Another strong correlation exists between themorning levels of alpha-amylase and satisfaction, so theremay be a connection between getting up, feeling less arousal,and feeling satis.ed.

Some participants reported a strong subjective and pos-itive reaction upon simply answering the questionnaires.Taking questions obviouslymade individuals re-ect on them-selves and their lives and some may have realized, just by.lling out the questionnaires, that they were not happy at all.*ismay have resulted, in some cases, in changes in their livesor life-styles (in a “positive intervention direction”).*e factthat the participants, including those in the control group,e,ectively changed some aspects of their daily life experience,as occasionally reported by participants and obviously due tothe “encounter” with our study battery could con.rm that themeasured e,ects and e,ect sizes (IG versus CG) are “real”.

It is possible that the training also initiated a “culturalchange,” possibly involving an improved work “climate” asincidentally reported by participants, through a conceivabledomino e,ect caused by the intervention group and com-mon hubs at the company (e.g., meeting each other at thecafeteria). *is would, once again, con.rm the statisticallymeasured di,erences between the IG and CG.

As the drop-out rate was quite high it might be suggestedthat an intention-to-treat analysis could have been moresuitable than our chosen analysis procedure (adherence-to-protocol).*e imputing of missing values (.lling in) is some-times seen as a possibility to replacemissing values. However,although this imputing technique of the “last observationcarried forward” is used, this approach has serious drawbackssuch as those participants who have been replaced withtheir own data contribute to results through untestableassumptions [)"]. By using adherence-to-protocol analyseswe tried to prevent the use of untestable assumptions.

In our study we did not investigate possible confounderslike age or sex. *is was a “speci.ed” setting study, which isfor the .rst time testing the hypotheses/outcome of e4cacyof a web-based happiness training in the work environment,therefore applying rigorous RCT methodology. Accordingly,the study cannot be seen or interpreted as an inductive, quasi-experimental design, much more as a .rst pilot study inthe area requested. However, due to practical and structuralconstraints produced by the chosen setting, and the actualcompany at hand (yet, we still consider the chosen company a“best possible choice”), we had to opt for complex randomiza-tion and strati.cation procedures, as described.Here, our.rstgoal was to achieve same-hierarchy, same-stress level andreporting categories (strata); therefore we did not adjust orstratify for age and sex. *is also met the company’s policiesfor not discerning results by gender. We could have adjustedand controlled for age, but we did not want to produce“overstatistics,” that is, providing too many di,erent analysisprocedures.

%.!. Limitations. Some limitations of our study must be men-tioned. Our .ndings are based on a sample that participatedvoluntarily and consisted largely of females (see Table !).*edrop-out rates were comparably high; however, both groups(IG and CG) where a,ected likewise.*e drop-outs resultedin especially low subsamples for the saliva and attentionsubgroups.

Moreover, because there were no timekeepers attachedto the saliva boxes and participants took saliva samples athome without supervision, we cannot guarantee that thesaliva samples were always collected at the correct time.

Since we used a waitlist control group design and not anactive control, measured e,ects between the IG andCG couldbe explained partly by expectation e,ects.

Furthermore we did not perform formal sample sizeestimation. Sample size considerations would have, in thisparticular case, contravened actual randomization proce-dures, and other on-site needs, since the department anddivision structures of the company, as well as the actual outletof diverse facilities, were the main determinant for feasibilityin this regard. However, we tried to acquire the biggestnumber of participants achievable. Besides that, comparablestudies in the same area have not been undertaken so farwith regard to web-based and occupational health-based,happiness-related “positive interventions.” As a consequence,our study could be interpreted with caution as a pilot studythat sparks interest in further research.

Another limitation of our study is no adjustment forpotential confounders, for example, age or sex. Further detailsare mentioned in the discussion.

*ese limitations could have in-uenced the results.

5. Conclusions

*e online happiness training led to higher scores in theself-report measures of happiness and life satisfaction. *etraining also had a positive e,ect on stress reactions becausethe individual awareness (perception) of stress decreasedsigni.cantly. *us, it appears that the online training maybe a useful tool in occupational health settings and amongemployees with high levels of work-related stress.

*ese results suggest that the training could be a toolwith some additional health-promoting or medical relevance(e.g., for primary care, health promotion, and preventivesettings). Hence, positive training e,ects were also seen inan increase in mindfulness, recovery experience, and -our-ishing. Moreover, e,ects of the training continued and werestill signi.cant, persisting )weeks a+er the end of the training(except for the muscular Stress Warning Signals and thevariable of “-ourishing” in the between-group analysis), thuspointing towards some sustained changes. *e training mayhave initiated a process within the participants that hada long-term (at least ) weeks) e,ect. However, underlyingmechanisms and mediators of said e,ects still remain to beelucidated.

Abbreviations

IG = Intervention group

Evidence-Based Complementary and Alternative Medicine #$

CG = Control group! = Signi.cance, ("! < 0.01, ""! < 0.001)" = Cohen’s ", = Correlation coe4cient* = MeanSD = Standard deviation.

Conflict of Interests

*e authors declare that there is a con-ict of interests regard-ing the cofunding of this study by the Humor Hil+ HeilenFoundation, whichwas founded by Eckart vonHirschhausen,one of the coauthors.

Acknowledgments

*e authors like to thankDr. Niko Kohls for statistical advice,Katharina Trikojat, Professor Dr. Clemens Kirschbaum, andDr. Jens Prussner for their consulting concerning salivasamples, Robin Switzer (MSPH, ELS) for proofreading andEnglish editing, ProfessorDr.*orsten Schafer for conferringwith us on the planned collection of data on sleep e4cacyand sleeping behaviors (they determined basic sleep-relatedaspects, but found no relevant outcomes or changes, this areacould be addressed in future studies), Professor Dr. SabineSonnentag for the use of the Recovery Experience Question-naire, and, last but not least, Dr. Ulrike Sonntag for hersupport in the pilot study. *is study was cofounded by theHumor Hil+Heilen foundation (Germany).

References

[#] M. E. Seligman andM. Csikszentmihalyi, “Positive psychology:an introduction,” .e American psychologist, vol. ((, no. #, pp.(–#), !""".

[!] R. Veenhoven, “World database of happiness: tool for dealingwith the ‘data-deluge’,” Psychological Topics, no. #3, pp. !!#–!)%,!""'.

[$] T. Esch, “Gesund im Stress: Der Wandel des Stresskonzeptesund seine Bedeutung fur Pravention, Gesundheit undLebensstil.,” Gesundheitswesen, vol. %), no. !, pp. &$–3#, !""!.

[)] T. Esch,G. B. Stefano,G. L. Fricchione, andH. Benson, “Stress incardiovascular diseases,” Medical Science Monitor, vol. 3, no. (,pp. RA'$–RA#"#, !""!.

[(] G. B. Stefano, H. Benson, G. L. Fricchione, and T. Esch, Eds.,.e Stress Response: Always Good and When It Is Bad, MedicalScience International, New York, NY, USA, !""(.

[%] A. O. K. WIdO, “Index" fur Arbeitsunfahigkeitstage und-falle aufgrund von psychischen Erkrankungen inDeuschland in den Jahren von #'') bis !"##,” !"#!,http://de.statista.com/statistik/daten/studie/!$'3%!/umfrage/index-fuer-arbeitsunfaehigkeitstage-und-faelle-aufgrund-von-psychischen-erkrankungen/.

[&] S. Lyubomirsky, L. King, and E. Diener, “*e bene.ts offrequent positive a,ect: does happiness lead to success?” Psy-chological Bulletin, vol. #$#, no. %, pp. 3"$–3((, !""(.

[3] S. Lyubomirsky, K. M. Sheldon, and D. Schkade, “Pursuinghappiness: the architecture of sustainable change,” Review ofGeneral Psychology, vol. ', no. !, pp. ###–#$#, !""(.

['] T. Esch,.e Neurobiology of Happiness. How Positive PsychologyChanges Medicine, Georg*ieme, Stuttgart, Germany, !"##.

[#"] N. L. Sin and S. Lyubomirsky, “Enhancing well-being andalleviating depressive symptomswith positive psychology inter-ventions: a practice-friendly meta-analysis,” Journal of ClinicalPsychology, vol. %(, no. (, pp. )%&–)3&, !""'.

[##] A. P. Jha, J. Krompinger, andM. J. Baime, “Mindfulness trainingmodi.es subsystems of attention,” Cognitive, A/ective andBehavioral Neuroscience, vol. &, no. !, pp. #"'–##', !""&.

[#!] T. Esch and G. B. Stefano, “*e neurobiology of stress manage-ment,”Neuroendocrinology Letters, vol. $#, no. #, pp. #'–$', !"#".

[#$] N. Rohleder, U. M. Nater, J. M. Wolf, U. Ehlert, and C.Kirschbaum, “Psychosocial stress-induced activation of salivaryalpha-amylase: an indicator of sympathetic activity?” Annals ofthe New York Academy of Sciences, vol. #"$!, pp. !(3–!%$, !"").

[#)] S.Wust, J.Wolf, D.H.Hellhammer, I. Federenko,N. Schommer,and C. Kirschbaum, “*e cortisol awakening response: normalvalues and confounds,” Noise Health, vol. !, no. &, pp. &'–33,!""".

[#(] U. M. Nater, N. Rohleder, W. Schlotz, U. Ehlert, and C.Kirschbaum, “Determinants of the diurnal course of salivaryalpha-amylase,” Psychoneuroendocrinology, vol. $!, no. ), pp.$'!–)"#, !""&.

[#%] A. O. K. WIdO, “Berufsgruppen mit den meistenArbeitsunfahigkeitstagen aufgrund von Burn-out-Erkrankungen im Jahr !"##,” !"##, http://de.statista.com/statistik/daten/studie/!$'%&!/umfrage/berufsgruppen-mit-den-meisten-fehltagen-durch-burn-out- erkrankungen/.

[#&] C. Begg, M. Cho, S. Eastwood et al., “Improving the qualityof reporting of randomized controlled trials: the CONSORTstatement,” Journal of the American Medical Association, vol.!&%, no. 3, pp. %$&–%$', #''%.

[#3] P. Bech, C. Gudex, and K. Staehr Johansen, “*e WHO (Ten)well-being index: validation in diabetes,” Psychotherapy andPsychosomatics, vol. %(, no. ), pp. #3$–#'", #''%.

[#'] A.-K. Allgaier, K. Pietsch, B. Fruhe, E. Prast, J. Sigl-Glockner,and G. Schulte-Korne, “Depression in pediatric care: is theWHO-Five Well-Being Index a valid screening instrument forchildren and adolescents?” General Hospital Psychiatry, vol. $),no. $, pp. !$)–!)#, !"#!.

[!"] B. A. Primack, “*e WHO-( Wellbeing Index performed thebest in screening for depression in primary care,” ACP JournalClub, vol. #$', no. !, article )3, !""$.

[!#] M. Bonsignore, K. Barkow, F. Jessen, and R. Heun, “Validityof the .ve-item WHO Well-Being Index (WHO-() in anelderly population,”EuropeanArchives of Psychiatry andClinicalNeuroscience, vol. !(#, supplement !, pp. !&–$#, !""#.

[!!] P. Bech, Quality of Life in the Psychiatric Patient, Mosby-Wolfe,London, UK, #''3.

[!$] T. Esch, U. Sonntag, S. M. Esch, and S. *ees, “Stress man-agement and mind-body medicine: a randomized controlledlongitudinal evaluation of students? Health and e,ects of abehavioral group intervention at aMiddle-SizeGermanUniver-sity (SM-MESH),” Forschende Komplementarmedizin, vol. !",no. !, pp. #!'–#$&, !"#$.

[!)] T. Esch, C. Gimpel, C. von Scheidt, G. Jose, and A. Michalsen,“*e Flourishing Scale (FS) by Diener et al. is now availablein an authorized German version (FS-D): application in mind-body medicine,” Forschende Komplementarmedizin, vol. !", no.), pp. !%&–!&(, !"#$.

#) Evidence-Based Complementary and Alternative Medicine

[!(] H. Walach, N. Buchheld, V. Buttenmuller, N. Kleinknecht, andS. Schmidt, “Measuring mindfulness-the Freiburg MindfulnessInventory (FMI),”Personality and IndividualDi/erences, vol. )",no. 3, pp. #()$–#(((, !""%.

[!%] S. Sonnentag and C. Fritz, “*e recovery experience question-naire: development and validation of a measure for assessingrecuperation and unwinding from work,” Journal of Occupa-tional Health Psychology, vol. #!, no. $, pp. !")–!!#, !""&.

[!&] E. Diener, D. Wirtz, W. Tov et al., “New well-being measures:short scales to assess -ourishing and positive and negativefeelings,” Social Indicators Research, vol. '&, no. !, pp. #)$–#(%,!"#".

[!3] N. Rohleder and U. M. Nater, “Determinants of salivary --amylase in humans and methodological considerations,” Psy-choneuroendocrinology, vol. $), no. ), pp. )%'–)3(, !""'.

[!'] U. M. Nater, N. Rohleder, J. Gaab et al., “Human salivaryalpha-amylase reactivity in a psychosocial stress paradigm,”International Journal of Psychophysiology, vol. ((, no. $, pp. $$$–$)!, !""(.

[$"] U. M. Nater, M. Bohus, E. Abbruzzese et al., “Increased psy-chological and attenuated cortisol and alpha-amylase responsesto acute psychosocial stress in female patients with borderlinepersonality disorder,” Psychoneuroendocrinology, vol. $(, no. #",pp. #(%(–#(&!, !"#".

[$#] U. M. Nater, C. A. Hoppmann, and S. B. Scott, “Diurnalpro.les of salivary cortisol and alpha-amylase change across theadult lifespan: evidence from repeated daily life assessments,”Psychoneuroendocrinology, vol. $3, no. #!, Article ID ""$!&-!,pp. $#&#–$#%&, !"#$.

[$!] J. Fan, B. D. McCandliss, T. Sommer, A. Raz, and M. I.Posner, “Testing the e4ciency and independence of attentionalnetworks,” Journal of Cognitive Neuroscience, vol. #), no. $, pp.$)"–$)&, !""!.

[$$] Y.-Y. Tang and M. I. Posner, “Attention training and attentionstate training,” Trends in Cognitive Sciences, vol. #$, no. (, pp.!!!–!!&, !""'.

[$)] R. Veenhoven, “Advances in understanding happiness,” RevueQuebecoise de Psychologie, vol. #3, no. !, pp. !'–&), #''&.

[$(] R. Veenhoven, “Healthy happiness: e,ects of happiness onphysical health and the consequences for preventive healthcare,” Journal of Happiness Studies, vol. ', no. $, pp. ))'–)%',!""3.

[$%] E.H. Blom, P. Bech,G.Hogberg, J.O. Larsson, andE. Serlachius,“Screening for depressed mood in an adolescent psychiatriccontext by brief self-assessment scales: testing psychometricvalidity of WHO-( and BDI-% indices by latent trait analyses,”Health and Quality of Life Outcomes, vol. #", article #)', !"#!.

[$&] P. Bech, L. R. Olsen, M. Kjoller, and N. K. Rasmussen, “Mea-suring well-being rather than the absence of distress symptoms:a comparison of the SF-$% mental health subscale and theWHO-.ve well-being scale,” International Journal of Methodsin Psychiatric Research, vol. #!, no. !, pp. 3(–'#, !""$.

[$3] P. Putz, M. Wittmann, and J. Wackermann, “Duration repro-duction: lossy integration and e,ects of sensory modalities,cognitive functioning, age, and sex,”Perceptual andMotor Skills,vol. ##(, no. !, pp. $&"–$3), !"#!.

[$'] P. A. M. van den Hurk, F. Giommi, S. C. Gielen, A. E. M.Speckens, and H. P. Barendregt, “Greater e4ciency in atten-tional processing related to mindfulness meditation,”QuarterlyJournal of Experimental Psychology, vol. %$, no. %, pp. ##%3–##3",!"#".

[)"] I. R.White, N. J. Horton, J. Carpenter, and S. J. Pocock, “Strategyfor intention to treat analysis in randomised trials with missingoutcome data,” British Medical Journal, vol. $)!, article d)",!"##.

Submit your manuscripts athttp://www.hindawi.com

Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2013

Oxidative Medicine and Cellular Longevity

Hindawi Publishing Corporation http://www.hindawi.com Volume 2013Hindawi Publishing Corporation http://www.hindawi.com Volume 2013

The Scientific World Journal

,QWHUQDWLRQDO�-RXUQDO�RI

(QGRFULQRORJ\+LQGDZL�3XEOLVKLQJ�&RUSRUDWLRQKWWS��ZZZ�KLQGDZL�FRP

9ROXPH��

ISRN AnesthesiologyHindawi Publishing Corporationhttp://www.hindawi.com Volume 2013

OncologyJournal of


PPARRe sea rch


OphthalmologyJournal of


ISRN AllergyHindawi Publishing Corporationhttp://www.hindawi.com Volume 2013

BioMed Research International


ObesityJournal of


ISRN AddictionHindawi Publishing Corporationhttp://www.hindawi.com Volume 2013


Computational and Mathematical Methods in Medicine

ISRN AIDSHindawi Publishing Corporationhttp://www.hindawi.com Volume 2013

Clinical &DevelopmentalImmunology

Hindawi Publishing Corporationhttp://www.hindawi.com

Volume 2013

Diabetes ResearchJournal of


Evidence-Based Complementary and Alternative Medicine

Volume 2013Hindawi Publishing Corporationhttp://www.hindawi.com


Gastroenterology Research and Practice


ISRN Biomarkers


MEDIATORSINFLAMMATION

of

evaluation of a seven-week web-based happiness training to … · 2015-03-17 · improve...

Documents