the health impact of residential retreats: a systematic review...6-day panchakarma ayurvedic retreat...
TRANSCRIPT
RESEARCH ARTICLE Open Access
The health impact of residential retreats: asystematic reviewDhevaksha Naidoo1, Adrian Schembri2 and Marc Cohen1*
Abstract
Background: Unhealthy lifestyles are a major factor in the development and exacerbation of many chronic diseases.Improving lifestyles though immersive residential experiences that promote healthy behaviours is a focus of the healthretreat industry. This systematic review aims to identify and explore published studies on the health, wellbeing andeconomic impact of retreat experiences.
Methods: MEDLINE, CINAHL and PsychINFO databases were searched for residential retreat studies in Englishpublished prior to February 2017. Studies were included if they were written in English, involved an intervention programin a residential setting of one or more nights, and included before-and-after data related to the health of participants.Studies that did not meet the above criteria or contained only descriptive data from interviews or case studies wereexcluded.
Results: A total of 23 studies including eight randomised controlled trials, six non-randomised controlled trials and ninelongitudinal cohort studies met the inclusion criteria. These studies included a total of 2592 participants from diversegeographical and demographic populations and a great heterogeneity of outcome measures, with seven studies examiningobjective outcomes such as blood pressure or biological makers of disease, and 16 studies examining subjective outcomesthat mostly involved self-reported questionnaires on psychological and spiritual measures. All studies reported post-retreathealth benefits ranging from immediately after to five-years post-retreat. Study populations varied widely and most studieshad small sample sizes, poorly described methodology and little follow-up data, and no studies reported onhealth economic outcomes or adverse effects, making it difficult to make definite conclusions about specificconditions, safety or return on investment.
Conclusions: Health retreat experiences appear to have health benefits that include benefits for people withchronic diseases such as multiple sclerosis, various cancers, HIV/AIDS, heart conditions and mental health. Future researchwith larger numbers of subjects and longer follow-up periods are needed to investigate the health impact of differentretreat experiences and the clinical populations most likely to benefit. Further studies are also needed to determine theeconomic benefits of retreat experiences for individuals, as well as for businesses, health insurers and policy makers.
Keywords: Wellbeing, Wellness tourism, Medical tourism, Lifestyle, Retreat experience, Multiple sclerosis, Cancer, Heartdisease, Mental health
BackgroundLifestyle-related chronic diseases such as obesity, dia-betes and lung disease are a global issue, which theWorld Health Organisation estimate account for 60% ofall deaths [1]. These diseases are characterised by modi-fiable risk factors such as physical inactivity, unhealthydiet such as diets high in salt, sugar, fat, alcohol and
tobacco, and exposure to environmental toxicants [1].Unhealthy lifestyles are a major factor in the develop-ment of chronic disease and are directly addressed bythe health retreat industry, which promises to deliver en-hanced health and the reversal of chronic disease andage-related conditions by engaging people directly inhealthy lifestyle behaviours and experiences [2–4].Health retreats have emerged from a history of travel
to foreign destinations such as spas, hot springs, sacredsites, and pilgrimage locations that have been used as
* Correspondence: [email protected] of Health and Biomedical Sciences, RMIT University, Plenty Rd,Bundoora, Bundoora, VIC 3083, AustraliaFull list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 DOI 10.1186/s12906-017-2078-4
places of rest and rejuvenation for countless generations[3, 5]. Such locations have given rise to a booming well-ness tourism industry that is estimated to have generatedUS$563.2 billion in revenues in 2015, with growth pro-jections that are nearly 50% faster than for overall globaltourism [6, 7]. A retreat may be defined as “a purpose-built centre which accommodates its guests for the pur-pose of learning/improving a body-mind activity (e.g.,yoga, pilates) and/or learning-receiving complementarytherapies or treatments whilst there” [2]. Retreats covera broad spectrum of facilities ranging from low-cost ash-rams in India [2, 3, 8] that focus on a spiritual-based life-style, to luxury lifestyle resorts [8], to residential centersthat focus on chronic disease. Retreat guests range frompeople who want to improve their general health andlearn positive lifestyle practices, to those facing life-threatening illnesses, and others who seek greater spirit-ual awareness or body-mind-spirit rejuvenation [9].Despite the growing popularity of retreats and the
growth of wellness tourism, the health impacts (eitherpositive or negative) of attending retreats are uncertainand it is unclear if retreats offer any economic return forindividuals or other stakeholders such as businesses,health insurance companies or governments. This paperaims to systematically review published studies that re-port on the health, wellbeing and economic impact ofretreat experiences according to the PICOS approach(Participants, Intervention, Comparators, Outcomes andStudy design) [10], and thereby explore the impact ofthese experiences on retreat guests.
MethodsSearch strategy and data sourcesA literature search was conducted in February 2017using the electronic databases MEDLINE, CINAHL, andPsychINFO using search terms as appropriate for eachof the databases. The search used combinations of key-words and phrases (retreat, health, wellness, wellbeing,resident) to conduct the systematic review. Truncationof keywords was used where variations of these wordsmay alter search results. In addition reference lists of allrelevant studies were manually searched.
Inclusion/ exclusion criteriaStudies were included if they were published prior toFebruary 2017, written in English, and contained beforeand after data related to health and wellbeing of retreatguests. As there is no strict definition of ‘retreat’, we in-cluded all studies that had at least one health-relatedoutcome and the intervention involved a residential set-ting of one or more nights. Studies that did not meet theabove criteria or contained only descriptive data frominterviews or case studies were excluded. We did not ex-clude studies based on the purpose of the retreat.
Data extractionEach potentially eligible study identified in the literaturesearch was independently screened according to the studyinclusion criteria and then independently reviewed.Detailed summary tables of the studies were prepared ac-cording to the PICOS approach [10]. Participants includedboth healthy people and people with specific diseases whoattended the relevant retreat program; the interventionswere all residential retreat programs that involved one ormore nights stay excluding hospital stays; comparisonswere made between post-retreat and pre-retreat measures;and outcomes included any physiological, psychological,or other clinically relevant outcomes. Data from all in-cluded studies were extracted by two independent authorsand presented in Tables 1, 2 and 3 along with p valueswhen p was less than 0.05.
Risk of bias assessmentTwo review authors independently assessed the risk of biasof each included Randomised Controlled Trial study usingthe Cochrane Risk of Bias tool including key criteria suchas random sequence generation, allocation concealment,blinding of participants, blinding of personnel and out-comes, incomplete outcome data, selective outcomereporting, and other sources of bias in accordance withmethods recommended by The Cochrane Collaboration[11]. The following judgements were used; low risk, highrisk or unclear (either lack of information or uncertaintyover poteintial for bias). Non-Randomised ControlledStudies and Longitudinal Cohort Studies were assessedusing the Risk of Bias in Non-Randomised Studies-of In-terventions (ROBINS-I) tool. Key criteria included con-founding, participant selection, intervention classification,deviations from intended interventions, missing data, out-comes measurement and reported results. The followingjudgements were used; low risk, moderate risk, serious risk,critical risk or no information. Authors resolved disagree-ments by consensus, and a third author was available forconsultation to resolve any discrepancies if necessary. Riskof bias assessments are summarised in Tables 4, 5 and 6.
ResultsThere were 23 studies (reported in 28 articles) included inthis systematic review, published over a 22-year periodfrom 1995 to 2017 and involving 2592 participants. Of the23 studies included, eight were randomised controlled tri-als (RCTs) including, one quasi-randomised trial and onerandomised multi-centre trial; six non-randomised con-trolled trails and nine longitudinal cohort studies. A studyflow chart is provided in Fig. 1. The results from the RCTsare presented in Table 1, results from the non-randomisedcontrolled trials are presented in Table 2 and results fromthe longitudinal cohort studies are presented in Table 3.
Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 Page 2 of 17
Table
1Summaryof
Rand
omised
Con
trolledTrialsof
RetreatInterven
tions
Reference
Stud
yde
sign
Popu
latio
n(includ
escomparatorgrou
p/s)
Interven
tion
Place(boldfont
indicatescoun
try)
Com
parator
Timingof
measures
OutcomeMeasures
Results
Epelet
al.,
2016
[1]
RCT
Health
ywom
en(n=94);Expe
rienced
med
itator(n=30),
Novicemed
itator
(n=33),Vacatio
n(n=31)
5-dayMed
itatio
nRetreat:
Med
itatonandyoga.
Cho
praCen
terfor
Wellbeing
,LaCosta
Resort,C
arlsbad,
California,U
nited
States
Vacatio
nat
the
samevenu
ewith
out
med
itatio
nretreatactivities
Pre-retreat,po
st-
retreat,1and10
mon
thspo
st-retreat.
Gen
eexpression
change
s(transcriptome-
wideexpression
patterns),
aging-relatedbiom
arkers
(telom
eraseactivity,A
βpe
ptidelevels),de
pressive
symptom
s,pe
rceived
stress,vitalityand
mindfulne
ss.
Highlysig.
Gen
eexpression
change
sob
served
across
all
grou
pspo
st-retreat
(the
‘vacationeffect’)
characterized
byim
proved
regu
latio
nof
stress
respon
se,immun
efunctio
nandam
yloid
beta
(Aβ)
metabolism.
Sig.im
provem
entin
all
grou
psin
depressive
symptom
s,pe
rceived
stress,m
indful
awaren
ess
andvitalityim
med
iately
afterand1-mon
thpo
st-retreat.The
novice
grou
pim
proved
sig
moreon
mindfulne
ssthan
theothe
rtw
ogrou
psat
day5andat
1-mon
thand10-m
onths
post-retreat.
Millset
al.,
2016
[2]
Quasi-
rand
omised
trial
Health
ymen
and
wom
en(n=119);I
ntervention(n=65),
Vacatio
n((n
=54)
6-dayPanchakarm
aAyurved
icRetreat‘Perfect
Health
(PH)P
rogram
’:Ph
ysicalcleansing
throug
hinge
stionof
herbs,fib
er,and
oils.
Twice-daily
Ayurved
iclight
plant-basedmeals.
DailyAyurved
icoil
massage
,heatin
gtreatm
ents(sauna
and/or
steam,lectureson
Ayurved
icprinciples,
lifestyle,m
editatio
nand
yoga
philosoph
y.Tw
ice-daily
grou
pmed
itatio
n,daily
yoga
andbreathingexercises
(pranayama),emotional
expression
throug
hjournalingandem
otional
supp
ort.Integrative
med
icalconsultatio
n(1-h)
with
aph
ysicianand
follow-upwith
Ayurved
iche
alth
educator.
Cho
praCen
terfor
Wellbeing
,LaCosta
Resort,C
arlsbad,
California,U
nited
States
Vacatio
nat
the
samevenu
ewith
out
med
itatio
nretreatactivities
Pre-retreat,po
st-
retreatand1and
10mon
ths
post-retreat.
TheSpirituality
Scale,
Gratitud
equ
estio
nnaire,
Self-Com
passionScale,
RyffScaleof
Psycho
logical
Wellbeing
,Cen
terfor
Epidem
iology
Stud
ies-
Dep
ression(CES-D)tool,
Patient-Rep
orted
Outcomes
Measuremen
tSystem
(PRO
MIS)A
nxiety
Scale.Otheroutcom
esobtained
wereBP,heigh
t,weigh
t(reported
inPeterson
2016)
Sig.increasesin
spirituality
(p<0.01)and
gratitu
de(p<0.05)in
the
retreatgrou
pandno
change
incontrolg
roup
.Sustaine
dincreasesin
spirituality
(p<0.01),
gratitu
de.and
self-
compassion(p<0.01)
andredu
cedanxiety
(p<0.05)at
1-mon
thfollow-up.
Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 Page 3 of 17
Table
1Summaryof
Rand
omised
Con
trolledTrialsof
RetreatInterven
tions
(Con
tinued)
Reference
Stud
yde
sign
Popu
latio
n(includ
escomparatorgrou
p/s)
Interven
tion
Place(boldfont
indicatescoun
try)
Com
parator
Timingof
measures
OutcomeMeasures
Results
Peterson
etal.,2016
[3]
RCT
Health
ymen
and
wom
en(n=119);
Interven
tion(n=65),
Vacatio
n(n=54)
6-dayPanchakarm
aAyurved
icRetreat‘Perfect
Health
(PH)P
rogram
’:Ayurved
iche
rbsusing
theZriipu
rifyhe
rbal
prog
ram,veg
etariandiet,
med
itatio
n,yoga,
Ayurved
icoilm
assage
,he
attherapiesand
lectures
onself-care
and
wellbeing
.
Cho
praCen
trefor
Wellbeing
,LaCosta
Resort,C
arlsbad,
California,U
nited
States
Vacatio
nat
the
samevenu
ewith
out
med
itatio
nretreatactivities
Preandpo
st-retreat
BMI,systolicanddiastolic
BP,heartrate,saliva,stoo
l,fastingbloo
dsample,
alcoho
luse,caffeineuse,
biolog
icalmarkersof
cell
biolog
y,ge
nome,
metabolom
eand
microbiom
e.Psycho
logical
indicesof
wellbeing
(reported
inMills2016)
Statisticallysig.
Chang
es(decrease)
inplasmalevelsof
phosph
atidylcholines,
sphing
omyelinsand
othe
rsafter6days.
Tarenet
al.,
2015
[4]
Sing
le-blind
RCT
Stressed
unem
ployed
job-seekingcommun
ityadults((n
=35);Inter
vention(n=18),Vac
ation(n=17)
3-dayEnhancem
ent
Throug
hMindfulne
ss(HEM
)Retreat:
Mindfulne
sstraining
throug
hbo
dyscan
awaren
essexercises,
sittingandwalking
med
itatio
ns,m
indful
eatin
gandmindful
movem
ent(gen
tlehatha
yoga
postures),discussion
ofindividu
alob
servations
andpractices.
Reside
ntialR
etreat,
Pittbu
rgh,
Penn
sylvania,U
nited
States
Vacatio
nat
the
samevenu
ewith
out
med
itatio
nretreatactivities
Pre-retreat(upto
4weeks
before),
post-retreat
(upto
2weeks
after)and
4 mon
thspo
st-
retreat
Neuroim
agingassessmen
t(re
stingstatefunctio
nal
conn
ectivity
(rsFC
)scan),
hairsample(cum
ulative
hypo
thalam
ic-pitu
itary-
adrenal(HPA
)axis
activation),Perceived
Stress
Scale(PSS).
Sig.change
sin
resting
statefunctionalconnectivity
(rsFC)intheright
amygdala-subgenual
anteriorcingulate
cortex(sgA
CC)of
interventiongroup
(time-treatment
interactionp<0.05).
Gilbertet
al.,
2014
[5]
RCT
Wom
en,age
d31
to60,w
ithno
med
itatio
nexpe
rience
(n=66)rand
omised
tointerven
tionor
vacatio
n((n
=no
trepo
rted
)control
(n=no
trepo
rted
)
5-dayresortstay
toattend
med
itatio
n,yoga,
awaren
essandself-
reflectiontraining
(interven
tion)
orto
relax
attheresortandreceive
health
lectures
(con
trol).
Both
grou
psreceived
the
samediet.
Cho
praCen
terfor
Wellbeing
,LaCosta
Resort,C
arlsbad,
California,U
nited
States
Vacatio
nat
the
samevenu
ewith
out
med
itatio
nretreatactivities
Pre-
andpo
st-
retreat
Stress,affect,reactivity
andrumination(end
-of
daydiaries).
Sig.increase
inpo
sitive
affect
andde
crease
inne
gativeaffect
post-
retreatin
theretreatbu
tno
tthecontrolg
roup
.Bo
thgrou
psfeltless
‘stressed
’post-retreat
(p’s<.001).O
nlyretreat
wom
enrepo
rted
sig.
Greater
controlo
ver
stressors(p=.01).A
llparticipantsrepo
rted
decreasedrumination
post-retreat,w
ithmore
pron
ounced
change
sin
theretreatgrou
p(p’s<.001).
Pidg
eon
etal.,2014
[6]
RCT
Hum
anservices
profession
als(n=44);
Interven
tion(n=22),
Nilinterven
tion
((n=22)
2.5-dayMindfulne
sswith
Metta
Training
(MMTP)
Retreatand2×4-Hou
rFollow-upover
12-w
eeks:
Perio
dsof
silence,training
inmindfulne
ssandmetta
skillsandcogn
itive
Reside
ntialFacility,
Southe
rnQueen
sland,
Australia
No
interven
tion
Pre-retreat,po
st-
retreat,1and4
mon
thspo
st-retreat
Resilience(The
Resilience
Scale),M
indfulne
ss(The
Five
FacetMindfulne
ssQuestionn
aire)and
Self-compassion(The
Self-Com
passionScale).
Nosig.
Differen
ces
repo
rted
immed
iately
post-retreat
with
sig.
Improvem
entsin
mindfulne
ssandself-
compassionin
theretreat
grou
pat
1-and4-
Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 Page 4 of 17
Table
1Summaryof
Rand
omised
Con
trolledTrialsof
RetreatInterven
tions
(Con
tinued)
Reference
Stud
yde
sign
Popu
latio
n(includ
escomparatorgrou
p/s)
Interven
tion
Place(boldfont
indicatescoun
try)
Com
parator
Timingof
measures
OutcomeMeasures
Results
therapystrategies
toincrease
mindfulne
ssand
self-compassion.Follow-
upinclud
edreview
and
practiceof
mindfulne
ss,
metta
andcogn
itive
strategies.
mon
thspo
st-retreat
and
inresilienceat
4-mon
ths
post-retreat.
Kwiatkow
ski
etal.,2013
[7]
Rand
omised
multicen
ter
trial
Non
-metastatic
breast
cancer
patientsin
completeremission
(n=232)
interven
tion
(n=117),con
trol
(n=115)
13-day
SPAstay
bysm
allg
roup
sof
patients
comprisingph
ysical
training
,dietary
education,ph
ysiotherapy
andSPAcares.
ThreeSPAcentres:
Vichy,Le-M
ont-Dore,
Chaˆtel-Guyon
,Fran
ce
Not
repo
rted
Pre-retreatand
every6mon
ths
post-retreat
for
next
3years
Anthrop
ometric
measures;
Qualityof
Life
(SF36
questio
nnaire),Anxiety
andDep
ression(Hospital
Anxiety
andDep
ression
(HAD)qu
estio
nnaire)
Sig.increase
inSF36
scoreby
9.5po
ints
(p<0.001),4.6(p<0.5)
and6.2(p<0.05)
respectivelyat
6,12
and
24mon
ths.Anxiety
and
depression
scorewere
redu
cedat
6,12
and24
mon
ths.
Brazieret
al.,
2006
[8]
RCT
HIV/AIDSpatients
(n=47);Interven
tion
(n=20),Standard
care
(n=27)
15-day
Art-of-Livingwith
HIV
RetreatandWeekly
Follow-upfor12
weeks:
Breathingtechniqu
es,
med
itatio
n,movem
ent
andgrou
pprocess.Three
breathingexercisesare
theessentialelemen
tsof
theprog
ram,p
articularly
theSudarshanKriyaor
HealingBreath.A
tthe
endof
theretreat,
participantsweregivena
daily
homepractice.
Follow-upsessions
includ
edreview
ing
proced
ures
from
retreat.
Reside
ntialA
OL
facilityin
Quebe
c,standard
care
and
follow-upin
Vancou
ver,Can
ada
Standard
care
Pre-retreatand1,6
and12
weeks
post
retreat
Gen
eralwell-b
eing
,Men
tal
Health
Inde
x(M
HI),Health
-relatedqu
ality
oflife(M
OS-
HIV
Survey),Stress
(Daily
Stress
Inventory(DSI)).
Sig.po
sitivechange
sin
wellbeing
,post-retreat
with
nochange
atlater
timepo
ints.
Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 Page 5 of 17
Table
2Summaryof
Non
-Rando
mised
Con
trolledTrialsof
RetreatInterven
tions
Reference
Stud
yde
sign
Popu
latio
n(includ
escomparatorgrou
p/s)
Interven
tion
Place(boldfont
indicatescoun
try)
Com
parator
Timingof
measures
OutcomeMeasures
Results
Al-H
ussaini
etal.,2001
[9]
Observatio
nal
stud
ywith
control
VipassanaMed
itatio
nCou
rseparticipants
(n=45);Interven
tion
(n=14),Nil
Interven
tion(n=31)
10-day
Vipassana
Med
itatio
nretreat
involvingsilent
sitting
and/or
walking
med
itatio
n,avoidance
ofcaffeineand
alcoho
l,specific
breathingpractices
anddaily
lectures.
Muscat,Oman
Nointerven
tion
Preandpo
st-
retreat
Gen
eralHealth
(Gen
eral
Health
Questionn
aire
(GHQ-28))
Sig.
improvem
ents
inph
ysicaland
psycho
logical
well-b
eing
inthe
Vipassanabu
tno
tcontrolg
roup
.
Khurana&
Dhar,2000
[10]
Observatio
nal
stud
ywith
controls
MaleandFemale
Prison
inmates
(n=150);Intervention
(n=75),Nil
Interven
tion(n=75).
10-day
Vipassana
Med
itatio
nretreat
involvingsilent
sitting
and/or
walking
med
itatio
n,avoidance
ofcaffeineand
alcoho
l,specific
breathingpractices
anddaily
lectures.
TiharJail,India
Nointerven
tion
Preandpo
st-
retreat
SubjectiveWell-b
eing
,scale),Q
ualityof
Life
(Life
SatisfactionScale),
Crim
inalProp
ensity
Scale.
Sig.
improvem
entsin
Crim
inalProp
ensity
and
SubjectiveWell-b
eing
inmaleinmates
ofVipassanagrou
pcomparedwith
conrol.
Emavardh
ana
&Tori,1997
[11]
Observatio
nal
stud
ywith
controls
Teen
agers,some
teache
rsandothe
radults(n=719);
Interven
tion(n=438),
NilInterven
tion
(n=281)
7-dayVipassana
Med
itatio
nretreat
involvingsilent
sitting
and/or
walking
med
itatio
n,avoidance
ofcaffeineand
alcoho
l,specific
breathingpractices
anddaily
lectures.
Youn
gBu
ddhists
AssociationRetreat
Center,Bangkok,
Thailand
Nointerven
tion
Preandpo
st-
retreat
SelfEsteem
(Ten
nessee
Self-Co
nceptScale(TSCS)),
LifeStyleIndex,Budd
hist
BeliefsandPractices
Scale
Sig.
improvem
entin
self-esteem
andself-
concep
tpo
st-retreat
Chand
iramani
etal.,1995
[12]
Observatio
nal
stud
y(study
I)Observatio
nal
stud
ywith
control(stud
yII)
Prison
inmates
(n=270);Study
I(n=120),N
ocomparator.Stud
yII
(n=150),Intervention
(n=85),Nil
Interven
tion(n=65).
10-day
Vipassana
Med
itatio
nretreat
involvingsilent
sitting
and/or
walking
med
itatio
n,avoidance
ofcaffeineand
alcoho
l,specific
breathingpractices
anddaily
lectures.
TiharJail,India
Nointerven
tion
Pre-retreat,po
st-
retreat,3and
6mon
thspo
st-
retreat(study
IIon
ly)
Well-b
eing
(Psycholog
ical
Gen
eralWell-b
eing
Inde
x(PGI)scale),H
ope(M
iller
andPo
wer
hope
scale),
hostility
questio
nnaire
Sig.
improvem
entin
physicaland
psycho
logicalh
ealth
intheinterven
tiongrou
p(Study
II).Bothstud
ies
show
edsig.
Redu
ctions
inanxietyand
depression
scores
post-
retreat(p<0.001)
inthe
Vipassanagrou
pbu
tno
tin
thecontrolg
roup
.
Garland
etal.,
2009
[13];
Garland
,2007
[14];A
ngen
etal.,2002
[15]
Long
itudinal
coho
rtstud
ywith
control
Advancedbreast,
prostate
orcolon
cancer
patients
(n=15),theirpartne
rs(n=15),natural
historygrou
pof
patients(n=20)and
theirpartne
rs(n=20)
5-dayTape
stry
Psycho
socialRetreat:
Intensivepsycho
social
interven
tionfor
palliativecare
patients
andtheirpartne
rsbasedon
the
Com
mon
wealC
ancer
HelpProg
ram.
Retreatand
Rene
walCen
tre
outsideof
Calgary,
Can
ada
Nointerven
tion
Pre-retreat,po
st-
retreat,1,3,6,9,
and12
mon
ths
post-retreat
Qualityof
Life
(Fun
ctional
Assessm
entof
Cancer
Therapy–Gen
eralForm
(FACT-G),McG
illQuality
ofLife
Questionn
aire
(MQOL),Q
ualityof
Life
inLife
Thretreatin
gIllne
ss–
Family
(QOLLTI-F)
questio
nnaire,Fatigue
Patientsin
thetape
stry
grou
pde
mon
stratedSig.
improvem
entin
marital
satisfaction(p=.011)
with
less
psycho
logical
wellbeing
(p=0.029),
supp
ort(p=0.021)
and
poorer
socialwellbeing
(p=0.01)th
anpatientsin
Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 Page 6 of 17
Table
2Summaryof
Non
-Rando
mised
Con
trolledTrialsof
RetreatInterven
tions
(Con
tinued)
Reference
Stud
yde
sign
Popu
latio
n(includ
escomparatorgrou
p/s)
Interven
tion
Place(boldfont
indicatescoun
try)
Com
parator
Timingof
measures
OutcomeMeasures
Results
(Fun
ctionalA
ssessm
entof
CancerTherapy–Fatig
ue(FACT-F)),Spirituality
and
Purpose(Fun
ctional
Assessm
entof
Chron
icIlnessandTreatm
ent-
SpirtualitySubscale
FACIT-Sp))Dep
ression
(BeckDep
ression
Inventory-II,Hop
elessness
Scale,BriefS
ymptom
Inventory-18),Inde
xof
maritalsatisfaction(IM
S).
thenaturalh
istory
grou
p.Partne
rsof
patientsin
the
Tape
stry
grou
prepo
rted
morefinancialworriesp
=0.05,and
less
marital
satisfactionp=0.05
than
partne
rsof
patientsno
tattend
ingtheretreat.
Both
theTape
stry
and
naturalh
istory
grou
psrepo
rted
morefatig
ueas
timeprog
ressed
regardless
ofgrou
ps.
Ornishet
al.,
2013
[16];
Ornishet
al.,
2008
[17]
Descriptive
stud
ywith
control
Men
with
biop
sy-
proven
low-risk
prostate
cancer
(n=35);Interven
tion
(n=10),Standard
care
(n=25)
3-dayLifestyle
Mod
ificatio
nRetreat
andOutpatient
phase
aspartof
3-mon
thCom
preh
ensive
LifestyleMod
ificatio
nProg
ram:Low
-fat,
who
lefood
s,plant-
baseddiet
with
supp
lemen
ts.Stress
managem
ent(gen
tleyoga-based
stretching
,breathing
,med
itatio
n,im
agery,
andprog
ressive
relaxatio
n),m
oderate
aerobicexercise
and
weeklygrou
psupp
ort
sessions.Edu
catio
nandcoun
selling
byregistered
dietitian,
exercise
physiologist,
clinicalpsycho
logist,
nurse,andstress
managem
ent
instructor.O
utpatient
phaseinclud
edweeklyteleph
one
contactwith
astud
ynu
rse.
Retreatlocatio
nno
trepo
rted
,UnitedStates
Standard
care
Pre-retreat,po
st-
retreatand5years
post-retreat
BMI,bloo
dpressure,
relativetelomereleng
thof
perip
heralb
lood
mon
onuclear
cells
and
telomeraseactivity,
Lifestyleadhe
rence
(Lifestyle-inde
xscores).
Sig.
improvem
entsin
weigh
t,abdo
minal
obesity,b
lood
pressure,
andlipid
profile
were
observed
(allP<0.05).
Sig.
increase
inrelative
telomereleng
thafter
5yearsin
retreatgrou
pcomparedto
decrease
incontrol.Adh
eren
ceto
lifestylechange
sassociated
with
sig.
Increase
intelomere
leng
thcomparedwith
control.
Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 Page 7 of 17
Table
3Summaryof
Long
itudinalC
ohortStud
iesof
RetreatInterven
tions
Reference
Stud
yde
sign
Popu
latio
n(includ
escomparatorgrou
p/s)
Interven
tion
Place(boldfont
indicatescoun
try)
Timingof
measures
OutcomeMeasures
Results
New
berg
etal.,
2017
[18]
Observatio
nal
stud
yChristianfaith
(n=14),
Nocomparator
7-dayIgnatianSpiritual
Retreat:Morning
mass,
person
alreflection,
contem
plation,prayer,d
aily
meetin
gwith
Spiritual
Director.M
ealseatenin
common
dining
area
with
othe
rretreatantsbu
ttypically
maintainoverallsilenceof
theretreat.
JesuitCen
ter,
Werne
rsville,
Penn
sylvania,
UnitedStates
Pre-retreat(upto
1mon
thbe
fore)
andpo
st-retreat
(up
to2weeks
after)
Dop
amineandseratonin
transporterbind
ingin
midbrain(DaTscan
sing
leph
oton
emission
compu
tedtomog
raph
y(SPECT
)),Speilberge
rState
TraitAnxiety
Inventory
(STA
I-Y),Profile
ofMoo
dsScale(POMS),Beck
Dep
ressionInventory
(BDI),ShortForm
Health
Survey
(SF-12),Cloning
erSelfTranscen
denceScale,
Spirituality
(Inde
xof
Core
SpiritualExpe
riences
(INSPIRIT))
Sig.
decreasesin
dopaminetransporter
bind
ingin
thebasal
gang
liaandin
serotonin
transporterbind
ingin
the
midbrainpo
st-retreat.Sig.
change
sin
avariety
ofpsycho
logicaland
spiritualmeasures
includ
ingim
provem
ent
inpe
rceivedph
ysical
health,d
ecreases
intensionandfatig
ue,m
ore
intensereligious
and
spiritualbe
liefs,feeling
morereligious
andmore
spiritualandincrease
infeelings
ofself-
transcen
dence.
Coh
enet
al.,
2017
[19]
Observatio
nal
stud
yGwingann
aLifestyle
retreatgu
ests(n=37),
Nocomparator
7-dayGwingann
aLifestyle
Retreat:Cho
iceof
nature
walks,b
oxing,
dance,spin
classes,qi
gong
,yog
a,Pilates,
med
itatio
n,ed
ucationaltalks,
spatreatm
ents,m
assage
,bo
dytreatm
ents,cou
nseling
sessions,and
othe
rhe
aling
mod
alities.O
rganicdiet
with
mainlyplant-basedfood
s,somefishandeg
gprotein,
noadde
dsugaror
salt,no
gluten
,dairy,caffeine,
alcoho
l,redmeat,or
cann
edor
packaged
food
.
Gwingann
aLifestyle
Retreat,Tallebu
dgera
Valley,Queen
sland,
Australia
Pre-retreat,po
st-
retreat,6weeks
post-retreat.
Heigh
t,weigh
t,abdo
minalgirth,bloo
dpressure,urin
arype
sticide
metabolites;food
and
health
symptom
questio
nnaire,FiveFactor
WellnessInventory(FFW
),Pittsburgh
Insomnia
Ratin
gScale(PIRS),
Dep
ression,Anxiety
Stress
Scales
(DASS),Profile
ofMoo
dStates
(POMS),
Gen
eralized
Self-Efficacy
Scale(GSE),Health
Symptom
Questionn
aire
(HSQ
),andCog
state
cogn
itive
functio
ntest
battery.
Sig.
improvem
entsin
allanthrop
ometric
measures(p<0.001)
and
psycho
logicaland
health
measures(p<0.05)po
st-
retreatwith
atren
dfor
improved
health
symptom
frequ
ency
and
severity.Health
symptom
frequ
ency
andseverity
continuedto
improve
andbe
camestatistically
sig.
6-weeks
post-retreat,
othe
rmeasuresredu
ced
somew
hatandwereno
long
erstatisticallysig.,
even
thou
ghthey
remaine
dbe
low
pre-
retreatlevels.
Steinh
ubletal.,
2015
[20]
Observatio
nal
stud
yExpe
rienced
and
novice
med
itators
(n=40);Expe
rienced
(n=20),Novice
(n=20)
7-dayWellnessretreat:Silent
mantramed
itatio
n,talks,
guided
deep
breathing
exercise
(pranayama),yog
aandothe
ractivities
supp
ortin
ginne
rcalm
inindividu
alandgrou
psettings.
Retreatlocatio
nno
trepo
rted
,United
States
Preandpo
st-retreat
Heartrate
andhe
artrate
variability(HRV),mean
arterialp
ressure,
electroe
ncep
halograph
((EEG
);14
sensorsplus
2references)
Sig.,m
easureableEEG
change
sin
expe
rienced
andno
vice
med
itators.
Med
itatio
nwas
associated
with
asm
all,
butstatisticallysig.
Decreasein
bloo
dpressure
ina
norm
oten
sive
popu
latio
n.
Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 Page 8 of 17
Table
3Summaryof
Long
itudinalC
ohortStud
iesof
RetreatInterven
tions
(Con
tinued)
Reference
Stud
yde
sign
Popu
latio
n(includ
escomparatorgrou
p/s)
Interven
tion
Place(boldfont
indicatescoun
try)
Timingof
measures
OutcomeMeasures
Results
Hadgkisset
al.,
2013a[21];Li
etal.,2010
[22].
Long
itudinal
coho
rtstud
yMultip
leSclerosis
patients(n=274);
Nocomparator
5-dayLifestyleMod
ificatio
nRetreat:Low-fat,plant-based
diet,exercise,sunlight
expo
sure,vitamin
Dand
omeg
a-3supp
lemen
tatio
n.Educationalp
rogram
,med
itatio
nandstress
redu
ctiontechniqu
es,
coun
selling
,yog
aand
qigo
ng.
TheGaw
lerFound
ation,
Victoria,A
ustralia
Pre-retreatand1,
2.5and5years
postretreat
(2.5years
phased
out)
Health
-related
quality
oflife(HRQ
OL),M
ultip
leSclerosisQualityOfLife
Questionn
aire
(MSQ
OL-54)
Sig.
improvem
entsin
HRQ
OLinclud
ingoverall
quality
oflifedo
main
(p<0.001);physical
health
compo
site
(p<
0.001);and
men
talh
ealth
compo
site
(p<0.001).
Furthe
rim
provem
entsat
5yearsforoverallq
uality
oflife;ph
ysicalhe
alth
compo
site
andmen
tal
health
compo
site
Vella
&Bu
ddet
al.,
2011
[23]
Observatio
nal
stud
yFemalereastcancer
patients(n=28);No
comparator
7-dayPh
otog
raph
icArt
TherapyRetreat:Ph
otog
raph
icarttherapyinconcertwith
psycho
analyticallyoriented
grou
ptherapy,mind-bo
dypractices
(optionalyog
aand
meditatio
n),lectures,
discussio
nandsupp
ort
grou
psandverylow-fat
diet
andexercise.
F.Holland
Day
Cen
ter
forCreativity
and
Healing,
Geo
rgetow
n,Maine
,UnitedStates
Pre-retreat,po
st-
retreatand6weeks
post-retreat
Anxiety,d
epression,and
somaticsymptom
s(Brief
Symptom
Inventory-18
(BSI)),Qualityof
life
(Fun
ctionalA
ssessm
ent
ofCancerTherapy-
Gen
eral(FACT
-G)),
Spiritualwell-b
eing
(Fun
ctionalA
ssessm
ent
ofChron
icIllne
ssTherapy-Spiritual
Well-b
eing
(FACIT-sp)
subscale).
Sig.
redu
ctions
inde
pression
,anxiety
and
somaticstress
andsig.
Improvem
entsin
QoL
andspiritualwellbeing
that
weresustaine
dafter
6weeks.
Con
boyet
al.,
2009
[24]
Observatio
nal
stud
yWom
en(n=20);No
comparator
5-dayPanchakarm
aAyurved
icRetreatand3-
weeks
(Min.)Pre-Retreatand
2-weeks
Post-Retreat:
Individu
alassessmen
ts,
massage
treatm
ents,
cleansingdiet,yog
asession,cookingclass
andgrou
pdiscussion
.Pre-interven
tioninclud
esgu
idance
tomod
ifydiet
andbe
gintaking
common
herbalsupp
lemen
ts.Post-
interven
tioncontinuesthe
cleansingprocesswith
lifestylerecommen
datio
nsto
maintainbalancelong
term
.
KripaluCen
trefor
Yoga
andHealth
,UnitedStates
Pre-retreat,po
st-
retreatand3mon
ths
post-retreat
Health
-Promoting
LifestyleProfile,Q
uality
oflife(SF-12),Selfefficacy
(singlemeasure),Anxiety
(BeckAnxiety
Inventory),
Socialsupp
ort
(InterpersonalSup
port
Evaluatio
nListand
SarasonScoialSupp
ort
Questionn
aire),Perceived
Stress
Scale).
Sig.
improvem
entsin
self-
efficacytowards
using
Ayurved
ato
improve
health
with
sig.
Improvem
entsin
perceivedsocialsupp
ort
andde
pression
3mon
ths
post-retreat
Kenn
edyet
al.,
2003
[25]
Observatio
nal
stud
yRice
DietProg
ram
Participants(n=101);
Nocomparator
10-day
(Min.)Rice
Diet
Retreat:Very
low-fatdiet
andexercise.O
ptional
participationin
yoga
and
med
itatio
nclasses.Lectures,
Durham,N
orth
Carolina,United
States
Preandpo
st-retreat
Spirituality
(3item
questio
nnaire),well-b
eing
(12item
questio
nnaire),
meaning
inlife(1
item
Increasedspirituality
positivelyassociated
with
increasedwell-b
eing
,increasedsenseof
meaning
andpu
rpose
Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 Page 9 of 17
Table
3Summaryof
Long
itudinalC
ohortStud
iesof
RetreatInterven
tions
(Con
tinued)
Reference
Stud
yde
sign
Popu
latio
n(includ
escomparatorgrou
p/s)
Interven
tion
Place(boldfont
indicatescoun
try)
Timingof
measures
OutcomeMeasures
Results
discussion
andsupp
ort
grou
ps,including
adiscussion
grou
pon
spirituality.
questio
nnaire)andange
r(4
item
questio
nnaire).
inlife,andde
creased
tend
ency
tobe
come
angry.
Beatus
etal.,
2002
[26]
Observatio
nal
stud
yPeop
lewith
Multip
leSclerosis(n=41)
6-daysummer
retreat
offeredannu
allyby
The
Multip
leSclerosisSocietyto
individu
alswith
MS.The
retreaten
courages
physical
activity,art,and
social
interaction.
Specificlocatio
nno
tstated
,UnitedStates
Pre-
andpo
st-
retreat
Rosenb
urgSelf-Esteem
Scale(Self-E
),Multip
leSclerosisQualityof
Life-54
Instrumen
t(M
SQOL-54),
Activities
ofDailyLiving
(Activities
ofDailyLiving
SelfCareScalefor
person
swith
multip
lesclorisis(ADL-MS).
Sig.
increase
inthe
men
talcom
pone
ntof
quality
oflife.
Kenn
edyet
al.,
2002
[27]
Observatio
nal
stud
yPatientswith
coronary
diseaseandtheir
partne
rs(n=72);
Patients(n=51),
Partne
rs(n=21)
2.5-dayEducationalR
etreat
‘Cho
iceto
Review
’:Ope
ndiscussion
swith
healthcare
profession
als,activities
such
asstress-red
uctio
ntechniqu
es,(prog
ressive
relaxatio
n,yoga,b
reathing
exercises,visualization,and
imagery),exerciseop
tions,
nutrition
alcoun
selingand
vege
tarianfood
,group
exercisesthat
encourage
self-efficacy,en
hancesocial
supp
ort,bu
ildself-esteem
andim
provecommun
ication
skills,andspiritualprinciples
andtechniqu
esforhe
aling
(med
itatio
n,prayer
and
forgivesne
ss)
Remotelocatio
n,UnitedStates
Pre-retreat,po
st-
retreatand4–
6mon
thspo
st-
retreat
Spirituality
(3item
questio
nnaire),well-b
eing
(12item
questio
nnaire),
meaning
inlife(1
item
questio
nnaire)andange
r(4
item
questio
nnaire).
Chang
esin
spirituality
werepo
sitivelyassociated
with
increasedwell-b
eing
,meaning
inlife,and
confiden
cein
hand
ling
prob
lems,andwith
decreasedtend
ency
tobe
comeangry.Nosig.
Differen
ces4and
6mon
thspo
st-retreat.
Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 Page 10 of 17
ParticipantsStudies in this review included a wide range of demo-graphic and socioeconomic backgrounds including luxuryresort guests [12–15], teachers [16], human service profes-sionals [17], unemployed adults [18], and prison inmates[19, 20]. The reviewed studies also included participantswith a wide range of health conditions. Eleven studies re-cruited participants in general health [12–15, 21–26], fourstudies recruited participants with mental health issuessuch as stress, fatigue or burnout [17–20], four studies re-cruited participants with cancers including prostate can-cer, breast cancer and colon cancer [27–30], two studiesrecruited participants with multiple sclerosis [31–33], andthe remaining two studies recruited participants withHIV/AIDS [34], and cardiac conditions [35].The sample size in each study ranged from 14 [21] to
719 [16] with participants recruited from various loca-tions including the local community and neighbouringareas [13–15, 17, 18, 21], specific medical facilities [28,34, 36], prisons [19, 20], and secondary schools and col-leges [16]. In four studies, participants were guests whohad already registered to attend the retreat and were
invited to participate in the research [12, 22, 24, 25].Some studies did not report on how participants wererecruited [23, 27, 31, 33, 35].
InterventionsThe retreat length of stays ranged from two and a halfdays [17, 35] to 15 days [34] with a duration of five toseven days being the most common [12–16, 21–23, 26,28, 31–33, 36]. Four retreats included a follow-up inter-vention period [17, 23, 27, 30, 34] that ranged in fre-quency, duration and mode of delivery from a couple offour-hour sessions over 12 weeks [17] to weekly follow-up via telephone over a three-month period [27].Retreat programs ranged from a focus on religion and
spirituality to lifestyle, health and wellbeing. Spirituality-focused retreats involved different spiritual/religiousdenominations and practices including mindfulness medi-tation [13, 17, 18, 34], Vipassana meditation [16, 19, 20,25], Ayurveda [14, 15] and Ignatian/Jesuit spirituality [21].These retreats included activities such as prayer, mass,chanting, observing silence and other techniques such asbreathing and mindfulness. Health and wellness-focused
Table 4 Risk of bias summary for Randomised Controlled Trial Studies
Randomsequencegeneration(selection bias)
Allocationconcealment(selection bias)
Blinding ofparticipantsand personnel(performance bias)
Blinding ofoutcomeassessment(detection bias)Self-reportedoutcomes
Incompleteoutcome data(attrition bias)
Selectivereporting(reporting bias)
Other bias
Epel et al., 2016 [1] Low Unclear High High Low Unclear Low
Mills et al., 2016 [2] High High High High High Unclear Low
Peterson et al., 2016 [3] High High High Low Low Unclear Low
Taren et al., 2015 [4] Low High High High Low Unclear Low
Gilbert et al., 2014 [5] Low Unclear Unclear High Unclear Unclear Low
Pidgeon et al., 2014 [6] Low Unclear Unclear High High Unclear Low
Kwiatkowski et al., 2013 [7] Low Unclear Unclear High Low Unclear Low
Brazier et al., 2006 [8] [6] Low Unclear Unclear High Unclear Unclear Low
Table 5 Risk of bias summary for Non-Randomised Controlled Trial Studies
Bias due toconfounding
Bias in selection ofparticipants intothe study
Bias in classificationof interventions
Bias due todeviationsfrom intendedinterventions
Bias due tomissing data
Bias inmeasurementof outcomes
Bias inselection ofthe reportedresult
Al-Hussaini et al., 2001 [9] Low Low Low Low Low Moderate Low
Khurana & Dhar, 2000 [10] Low Low Low Low Low Moderate Low
Emavardhana & Tori, 1997 [11] Low Low Low Low Low Moderate Low
Chandiramani et al., 1995 [12] Low Low Low Low Low Moderate Low
Garland et al., 2009 [13];Garland, 2007 [14]; Angenet al., 2002 [15]
Low Low Low Low Low Moderate Low
Ornish et al., 2013 [16];Ornish et al., 2008 [17]
Low Low Low Low Low Low Low
Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 Page 11 of 17
retreats included activities such as exercise, yoga, bodytreatments, medical consultations, counselling, supportgroups and discussion [12, 22, 27, 31, 33]. Both spiritually-focused and health-focused retreats commonly includedmeditation as an activity, sometimes optional, along witha focus on either a prescribed diet such as organic diet,[12] vegetarian diet [15, 35] or low-fat diet, [24, 27, 28, 31,33] or dietary education such as mindful eating [16, 18] ornutritional counselling. [35] In the four studies with afollow-up intervention, activities included review andpractice of techniques taught at the retreat such as mind-fulness, [17, 34] the continuance of practices and pro-cesses that began at the retreat such as lifestyle changesand cleansing, [23] or telehealth support from a studynurse [27].
PlaceMore than half of the studies (13) were conducted in theUnited States [13–15, 18, 21–24, 27, 28, 35], three stud-ies were conducted in Australia [12, 17, 31, 33], twostudies each were conducted in Canada [29, 34, 36] andIndia [19, 20], and the remaining three studies were con-ducted in Oman [25], Thailand [16] and France [30].Studies were held at specifically designed retreat cen-
tres [34, 36], residential facilities such as religious cen-tres [16, 21] or prisons [19, 20] as well as yoga [23] andhealing retreat facilities [28]. Four studies were con-ducted with guests staying at luxury resorts, one inQueensland, Australia [12], and three at the same resortin California, United States [13–15]. Both studies con-ducted in India were conducted at a prison in New Delhifor prisoners [19, 20]. Three studies did not report thespecific location of the retreat [18, 22, 27].
ComparatorsOf the eight controlled trials reviewed, five included vac-ation groups [13–15, 18, 26], who visited the same
Table 6 Risk of bias summary for Longitudinal Cohort Studies
Bias due toconfounding
Bias in selectionof participantsinto the study
Bias inclassificationof interventions
Bias due todeviationsfrom intendedinterventions
Bias due tomissing data
Bias inmeasurementof outcomes
Bias in selectionof the reportedresult
Newberg et al., 2017 [18] Low Low Low Low Low Moderate Low
Cohen et al., 2017 [19] Low Low Low Low Low Moderate Low
Steinhubl et al., 2015 [20] Low Low Low Low Low Moderate Low
Hadgkiss et al., 2013a [21];Li et al., 2010 [22].
Low Low Low Low Low Moderate Low
Vella & Budd et al., 2011 [23] Low Low Low Low Low Moderate Low
Conboy et al., 2009 [24] Low Low Low Low Low Moderate Low
Kennedy et al., 2003 [25] Low Low Low Low Low Moderate Low
Beatus et al., 2002 [26] Low Low Low Low Low Moderate Low
Kennedy et al., 2002 [27] Low Low Low Low Low Moderate Low
4609 potentially relevant articles identified from searches until February 2017Medline 2315PsycINFO 915CINAHL 322
4505 articles excluded after title and abstract review or duplicates
103 articles retrieved for more detailed evaluationMedline 65PsycINFO 23CINAHL 15
75 articles excluded after full review as did not fulfil inclusion criteria ie. non-residential retreat study, no before/ after outcome data
8 RCTs8 Articles
9 Longitudinal Cohort Studies
17 Articles
8 Additional articles identified from references
(23 studies) 28 articles met inclusion criteria and included in review
6 Non-Randomised CTs
3 Articles
Fig. 1 Study Flow Chart
Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 Page 12 of 17
retreat purely for relaxation purposes without participa-tion in organised retreat activities. One of these studiesincluded an additional comparator group to compare re-sults between novice and experienced meditators [13].One study for HIV/AIDS patients had a group who con-tinued to receive their standard care [34], and two stud-ies; one for Human Service Professionals and anotherfor non-metastatic breast cancer patients, had a groupwho received no intervention [17, 30].Of the six non-randomised controlled trials reviewed,
five studies included comparator groups who receivedno intervention [16, 19, 20, 25, 29] and one study in-cluded a group who received standard care [27]. Onlytwo of the nine longitudinal cohort studies included acomparator group, with one study comparing resultsfrom novice to experienced meditators [22] and anothercomparing results from healthy heart patients to theirpartners [35].
Outcome measuresAll studies reported statistically significant improve-ments in at least one measured outcome at some timeafter retreat. Outcomes ranged from subjective measuresusing standardized self-reported questionnaires for well-being [14, 36], quality of life [19, 28–30, 36] and per-ceived stress [12, 13, 18, 23, 26, 28, 34] such as; TheGratitude, Resentment and Appreciation Test (GRAT-sf ) [37, 38], The Ryff Scale of Psychological Wellbeing[39], and the Mental Health Index (MHI) [40]; to object-ive measures such as abdominal girth [12, 15, 27], bloodpressure [12, 15, 22, 27] and analysis of urine [12], blood[13–15, 26, 27], hair samples [18], neuroimaging [18],cognitive function [12], gene expression [13] and themetabolome [15]. All studies included at least one before(pre-retreat) and one after (post-retreat) measurementwith most studies including more than one post-retreat measurement, ranging from one month post-retreat [13, 14, 17, 36] to five years post-retreat [27, 31].No studies reported any adverse effects or economicoutcomes.
Summary of objective and subjective outcomesAll studies reported statistically significant improve-ments in at least one measured outcome with only onestudy of 44 human service professionals undertaking atwo-and-a-half day Mindfulness with Metta Training(MMTP) Retreat, reporting no significant differences inself-report measures of resilience, mindfulness and self-compassion immediately after the retreat experience,despite significant improvements for mindfulness andself-compassion at one and four months and for resili-ence at four months post-retreat [17]. A further study of47 patients with HIV/AIDS who participated in a 15-day‘Art-of-Living with HIV’ retreat reported significant
positive changes in wellbeing immediately after the re-treat, that were not evident after 6 and 12 weeks [34].
Objective/ quantitative outcomesAll seven studies investigating objective outcomes reportedstatistically significant improvements immediately after theintervention. Three of these studies reported significantimprovements in anthropometric measures such as weight,abdominal girth and blood pressure [12, 23, 27, 41] and re-ductions in blood lipids [41]. Statistically significant resultswere also reported for decreases in dopamine transporterbinding in the basal ganglia and serotonin transporterbinding in the midbrain [22]; changes in resting state func-tional connectivity (rsFC) in the right amygdala-subgenualanterior cingulate cortex (sgACC) [18]; reductions in 12phosphatidylcholines and an additional 57 metabolitessuch as amino acids, biogenic amines, acylcarnitines, gly-cerophospholipids and sphingolipids [15]; gene expressionchanges associated with improved regulation of stress re-sponse, immune function and amyloid beta (Aβ) metabol-ism [13]; and electroencephalogram (EEG) changes [22].Ornish et al. [27] further documented increases in relativetelomere length after five years that was associated withthe degree of adherence to lifestyle changes in ten of 35men with biopsy-proven prostate cancer [27, 41].
Subjective/ qualitative outcomesFifteen of the 16 studies investigating subjective or survey-based outcomes reported statistically-significant improve-ments immediately post-retreat including significant im-provements in quality of life, perceived physical health andhealth symptoms, as well as a variety of psychological andspiritual measures [12–14, 16, 17, 19–21, 23, 25, 28, 29, 31,34, 36]. Two studies reported improvements in overallhealth-related quality of life [28, 31] and four studies im-provements in perceived physical health [20, 21, 25, 31].Cohen et al. [12] reported improvements in both subjectiveand outcome measures including cognitive function andConboy et al. [23] reported improvements in positivehealth behaviours and self-efficacy.Eight of the nine studies measuring psychological well-
being reported statistically significant improvements in avariety of indicators including depression, anxiety, tension,stress, fatigue, mindful awareness and vitality [12, 13, 20,21, 25, 28, 29, 31, 36]. Khurana and Dhar [19] reportedimprovements in subjective wellbeing and criminal pro-pensity, however this improvement was only seen in maleinmates of the intervention group, and not in female in-mates or the control group that did not receive the inter-vention. All six studies measuring spiritual wellbeingreported significant improvements in various religious andspiritual measures [14, 16, 21, 24, 28, 35]. Vella and Budd[28] reported improvements in overall spiritual wellbeingand Mills et al. [14] reported a significant increase in
Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 Page 13 of 17
spirituality and gratitude in the intervention group thatparticipated in a six-day Panchakarma Ayurvedic pro-gram, compared with no change in the control group thatwere on vacation at the same resort. Newberg et al. [21]reported significant changes such as more intense reli-gious and spiritual beliefs, feeling more religious and morespiritual, and an increase in feelings of self-transcendencein 14 participants of a Christian faith.Two studies [24, 35] investigating the relationship be-
tween spirituality and health measures, found that mea-sures of spirituality increased after a retreat along withincreased well-being, sense of meaning and purpose inlife, confidence in handling problems and a decreasedtendency to become angry. Similarly, Emavardhana andTori [16] found that heightened belief in Buddhist pre-cepts was associated with positive change in self-conceptand less self-criticism and increased Buddhist religiositywas correlated with reductions in the defences of dis-placement, projection and regression [16].
Risk of biasAll Randomised Controlled Trial Studies were found tohave low, unclear or high risk of bias in one or more do-mains. The most high risk was reported for blinding ofoutcome assessment. Allocation concealment and re-ported data selection was not reported for the majorityof studies and therefore unclear. All Non-RandomisedControlled Trial Studies and Longitudinal Cohort Stud-ies were found to have low risk of bias for all domainsexcept outcomes measures. All but one study [41] failedto report whether or not the outcomes assessor wasaware of the participant intervention and were thereforefound to have a moderate risk of bias for outcomesmeasurement. Given these findings, all studies are com-parable to a well-performed randomised trial with regardto the majority of domains (low risk) except outcomesmeasurement (moderate risk) indicating the studies aresound for a non-randomised study with regard to thisdomain but cannot be considered comparable to a well-performed randomized trial,
DiscussionThe retreat industry is a niche sector of the wellnesstourism industry that focuses on transformative experi-ences that aim to improve the health of participantsthrough healthy lifestyle experiences, along with provid-ing the skills and knowledge to help maintain healthybehaviours. The findings from the reviewed studies sug-gest there are many positive health benefits from retreatexperiences that includes improvements in both subject-ive and objective measures. Most studies used a quasi-experimental design with small sample sizes, poorlydescribed methodology with little follow-up data andreliance on self-report questionnaires to report on
psychological and spiritual benefits. The results from themost rigorous studies that used randomized controlleddesigns were consistent with less rigorous studies andsuggest that retreat experiences can produce benefitsthat include positive changes in metabolic and neuro-logical pathways, loss of weight, blood pressure andabdominal girth, reduction in health symptoms and im-provements in quality of life and subjective wellbeing.In addition to facilitating general health improve-
ments, there is evidence that retreat experiences canhave a positive impact on chronic disease processes andprovide benefits for some people with life threateningand/or chronic diseases. Of the four studies of retreatexperiences aimed at improving quality of life for cancerpatients [27, 28, 30, 36], all showed some benefits fromretreat participation, including improvements in qualityof life, depression and anxiety scores, and increased telo-mere length, with benefits being recorded up to fiveyears post-retreat. Similarly, benefits of retreat participa-tion are reported for people with multiple sclerosis withimprovements in quality of life along with physical andmental health being evident up to five years post-retreat[31, 32]. Not all measures in the studies of life-threatening chronic diseases improved [30, 36], and asthey are all small, poorly-controlled studies, more rigor-ous research is needed.The finding that retreat experiences can lead to sus-
tained and significant health improvements long afterparticipants return home suggests that these experiencesassist guests in making positive lifestyle changes andadopting healthy behaviours that lead to a variety ofpositive psychological, physiological, cognitive, clinicaland metabolic effects. The ability to influence partici-pants’ health once they return home is dependent onmany factors including the type of participants involved,the education and experiences provided during the re-treat program, and the provision of follow-up activitiessuch as online coaching, nutrition programs, or follow-up consultations with practitioners. Of the four studiesthat showed a reduced effect over time in some mea-sures [12, 17, 34, 35], two studies did not include afollow-up retreat component [12, 35].While it is not pos-sible to determine which parts of the retreat interventionhave the greatest influence, it is likely that improvementsin health are due to a combination of psychological andbehavioural factors that lead to better coping mecha-nisms and enhanced resilience to stress, as well as meta-bolic factors that lead to alterations in gene expressionand DNA repair mechanisms that are evident in the ob-served changes in the metabolome [15] and teleomerelength [27, 41].Despite the potential for retreat experiences to benefit
people with chronic and life threatening disease, the re-treat industry does not routinely interact with the health
Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 Page 14 of 17
care sector with few patients being referred to retreatsby medical practitioners and retreat experiences gener-ally not covered by third party payment schemes or eli-gible for tax deductions or incentives. The lack ofintegration between the healthcare and retreat sectorsmay be partly due to a lack of data with which to evalu-ate retreat experiences. Few retreats routinely collectand/or communicate data relevant to the healthcaresector, and even when formal studies such as thosereviewed here are conducted, there is great heterogen-eity in the range and scope of outcome measures, withfew measures being comparable across studies. The re-treat industry would therefore benefit from the use of astandardised dataset collected from guests on a routinebasis. Such data could include a combination of psycho-logical, cognitive, physiological, anthropometric and bio-chemical measures that together provide a holisticassessment of outcomes. This would allow retreat partic-ipants to evaluate and monitor the impact of their expe-riences and provide data to engage the medicalprofession and third party payers. It would also be bene-ficial for the industry to develop a standardised reportingsystem for retreat activities so that the influence of dif-ferent types of retreat experiences can be assessed andresults meaningfully compared across retreats andstudies.While retreat experiences appear to have positive
health impacts, there is no published data on the eco-nomic impact of retreat experiences. There is however,substantial evidence that non-residential wellness pro-grams, which share a similar focus on health promotionand lifestyle modification, provide a substantial eco-nomic return [42–44]. A review of 28 studies of corpor-ate wellness programs [45] finds that the economicbenefit of participation is substantially higher than thecosts of providing the program. Stead [45] reportsbenefit-to-cost ratios averaging 3.4–1 which indicatesthat corporate companies receive on average US$3.40for every US$1 invested in the respective wellness pro-gram. In addition to return on investment, employeesbenefit from participating in corporate wellness pro-grams through experiencing better health, lowered dis-ability payments and reduced health care expenditures,while companies benefit from reduced employee turn-over, increased productivity [45] and reduced absentee-ism and presenteeism along with intangible benefitssuch as being an employer of choice and attractinghighly skilled employees and creating a positive corpor-ate culture [45, 46].While the economic benefits of corporate wellness
programs are becoming well established, it is unclear ifsimilar benefits are offered by residential retreats. Futurestudies that include a health economic analysis aretherefore needed to determine the cost-benefits of
retreat experiences and the return on investment forparticipants, businesses, health insurers and policymakers. This may enable retreat operators to advocatefor tax benefits, as well as inclusion in health insurancepolicies, and corporate wellness schemes. Furthermore,there is no data on the occurrence of adverse events. Fu-ture studies would benefit from including measures ofadverse outcomes to confirm the safety and efficacy ofretreat interventions.Despite the consistent reporting of positive health ef-
fects from retreat interventions across multiple study de-signs and locations, the ability to draw definitiveconclusions for any one condition or population is lim-ited due to poor methodological rigor and substantialheterogeneity in study design, length and type of retreatprogram, target population, outcome measures andlength of follow-up. Furthermore, while the reviewedstudies included subjects from a wide range of demo-graphic groups in multiple countries, only publishedEnglish language studies were reviewed and it is uncer-tain if the findings can be generalized to the wider popu-lation. The use of mostly self-selected populations alsointroduces the possibility of selection bias, while a lackof blinding and adequate controls may introduce per-formance bias due to exposure to factors other than thespecific intervention such as the vacation effect wherebyhealth can improve from simply being removed fromnormal routines and behaviours. The lack of any re-ported adverse events may further indicate reportingbias with researchers not actively looking to identify ad-verse outcomes, or outcome measurement tools not be-ing designed to capture adverse outcomes. Futurestudies, with more rigorous methodology and long-termfollow-ups are now needed to determine the longevity ofany effects, their mechanisms of action and the condi-tions most likely to respond.
ConclusionThe findings of this review suggest that retreat experi-ences appear to have positive health benefits that includebenefits for people with chronic diseases. As the ob-served improvements in chronic diseases are based on asmall number of patients, future research using largernumbers of subjects and longer follow-up periods isneeded in order to determine the populations mostlikely to benefit and quantify any long-term health bene-fits. Future studies could also benefit from more rigor-ous study designs including the use of standardizedoutcome measures, more detailed descriptions of the re-treat interventions and study population, and the inclu-sion of a health economics analysis in order todetermine the economic benefits of retreat experiencesfor individuals, as well as for businesses, health insurersand policy makers.
Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 Page 15 of 17
AbbreviationsAβ: Amyloid Beta; BMI: Body Mass Index; BP: Blood Pressure;DNA: Deoxyribonucleic Acid; EEG: Electroencephalogram; GRAT-sf: TheGratitude, Resentment and Appreciation Test; HIV/AIDS: HumanImmunodeficiency Virus and Acquired Immune Deficiency Syndrome;MHI: Mental Health Index; MS: Multiple Sclerosis; MTTP: Mindfulness withMeta Training Program; PICOS: Participant, Intervention, Comparators,Outcomes and Study Design); PwMS: People with Multiple Sclerosis;RCT: Randomised Controlled Trial; RsFC: Resting state functional connectivity;SgACC: subgenual anterior cingulate cortex; WHO: World Health Organisation
AcknowledgementsThere are no specific acknowledgements to make.
FundingThe authors of this study have not received any funding to support thisSystematic Review.
Availability of data and materialsThe data for this paper was obtained from published papers reported in thereference section and as such, has not been placed in a data repository.
Authors’ contributionsDN contributed to the planning and design of the methodology for thissystematic review. DN conducted the searches to find appropriate papers forthis systematic review. DN appraised papers to determine whether or notthey met criteria to be included in this review. DN extracted data from thepapers. DN conducted searches to find background material for this paper.DN undertook the initial write-up of all sections of this paper includingreferencing. DN corresponded with the other authors to obtain reviewand comments on this paper. DN revised several versions of this paper.MC led the planning and design of the methodology for this systematicreview. MC reviewed all papers in this review according to the inclusioncriteria. MC led meetings between DN, MC and AS regarding the methodology,data extraction, write-up and preparation of this paper. MC reviewed this paperon several occasions including revision of all materials. AS reviewed themethodology for this systematic review. AS contributed to the discussionand planning of preparing this paper. AS reviewed this paper and includedcomment, feedback and multiple revisions. All authors read and approved thefinal manuscript.
Authors’ informationMC is a Registered Medical Practitioner, Professor of Health Sciences at RMITUniversity and a Board Member at the Global Wellness Summit.AS is a Clinical Psychologist and an employee of Cogstate.DN holds a Bachelor degree in Health Science from the University ofAuckland and is undertaking an Honours in Health and Biomedical Sciencesat RMIT University.
Ethics approval and consent to participateAs this paper describes literature-based research, ethics approval is notrelevant.
Consent for publicationNot applicable.
Competing interestsMC is a board member of the Global Wellness Summit and has previouslybeen a paid presenter at the Gwinganna Health Retreat. RMIT University hasreceived donations from Danubius Hotel Group, Lapinha, Sunswept Resorts,Sheenjoy and The Golden Door for ongoing retreat research.
Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims in publishedmaps and institutional affiliations.
Author details1School of Health and Biomedical Sciences, RMIT University, Plenty Rd,Bundoora, Bundoora, VIC 3083, Australia. 2Cogstate Limited, Melbourne 3000,Australia.
Received: 3 August 2017 Accepted: 29 December 2017
References1. World Health Organisation. Preventing Chronic Diseases. A Vital Investment:
WHO Global Report., Geneva: World Health Organization. . 2005. www.who.int/chp/chronic_disease_report/en.
2. Smith M, Kelly C. Holistic tourism: journeys of the self? Tour Recreat Res.2006a;31(1):15–24. https://doi.org/10.1080/02508281.2006.11081243.
3. Smith M. Holistic holidays: tourism and the reconciliation of body, mind andSpirit. Tour Recreat Res. 2003;28(1):103–8. https://doi.org/10.1080/02508281.2003.11081392.
4. Smith M, Kelly C. Wellness tourism. Tour Recreat Res. 2006b;31(1):1–4.https://doi.org/10.1080/02508281.2006.11081241.
5. Gesler WM. Therapeutic landscapes: medical issues in light of the newcultural geography. Social science & medicine (1982). 1992;34(7):735.
6. Yeung O, Johnston K. Global wellness economy monitor. Miami, Fl: GlobalWellness Institute2017.
7. Yeung O, Johnston K. The Global Wellness Tourism Economy. Miami, Fl:Global Wellness Institute 2014 March 1 2017.
8. Lea J. Retreating to nature: rethinking ‘therapeutic landscapes. Area. 2008;40(1):90–8. https://doi.org/10.1111/j.1475-4762.2008.00789.x.
9. Kelly C. Wellness tourism: retreat visitor motivations and experiences. TourRecreat Res. 2012;37(3):205–13. https://doi.org/10.1080/02508281.2012.11081709.
10. Methley AM, Campbell S, Chew-Graham C, McNally R, Cheraghi-Sohi SPICO.PICOS and SPIDER: a comparison study of specificity and sensitivity in threesearch tools for qualitative systematic reviews. BMC Health Serv Res. 2014;14(1):579. https://doi.org/10.1186/s12913-014-0579-0.
11. Higgins JP, Green S, editors. Cochrane Handbook for Systematic Reviews ofInterventions Version 5.1.0 [updated March 2011]. The CochraneCollaboration; 2011.
12. Cohen MM, Elliott F, Oates L, Schembri A, Mantri N. Do Wellness TouristsGet Well? An Observational Study of Multiple Dimensions of Health andWell-Being After a Week-Long Retreat. Journal of alternative andcomplementary medicine (New York, NY). 2017;23(2):140–8. https://doi.org/10.1089/acm.2016.0268.
13. Epel ES, Puterman E, Lin J, Blackburn EH, Lum PY, Beckmann ND, et al.Meditation and vacation effects have an impact on disease-associatedmolecular phenotypes. Transl Psychiatry. 2016;6:e880. https://doi.org/10.1038/tp.2016.164.
14. Mills PJ, Wilson KL, Pung MA, Weiss L, Patel S, Doraiswamy PM, et al. Theself-directed biological transformation initiative and well-being. The Journalof Alternative and Complementary Medicine. 2016;22(8):627–34. https://doi.org/10.1089/acm.2016.0002.
15. Peterson CT, Lucas J, John-Williams LS, Thompson JW, Moseley MA, Patel Set al. Identification of altered Metabolomic profiles following aPanchakarma-based Ayurvedic intervention in healthy subjects: the self-directed biological transformation initiative (SBTI). Sci Rep 2016;6:32609.https://doi.org/10.1038/srep32609. http://www.nature.com/articles/srep32609 - supplementary-information.
16. Emavardhana T, Tori CD. Changes in self-concept, ego defense mechanismsand religiosity following seven-day Vispassana meditation retreats. TheJournal for the Scientific Study of Religion. 1997;36(2):194–206.
17. Pidgeon AM, Ford L, Klaassen F. Evaluating the effectiveness ofenhancing resilience in human service professionals using a retreat-based mindfulness with Metta training program: a randomised controltrial. Psychology, health & medicine. 2014;19(3):355–64. https://doi.org/10.1080/13548506.2013.806815.
18. Taren AA, Gianaros PJ, Greco CM, Lindsay EK, Fairgrieve A, Brown KW, et al.Mindfulness meditation training alters stress-related amygdala resting statefunctional connectivity: a randomized controlled trial. Soc Cogn AffectNeurosci. 2015;10(12):1758–68. https://doi.org/10.1093/scan/nsv066.
19. Khurana A, Dhar PL. Effect of Vipassana meditation on quality of life,subjective well-being, and criminal propensity among inmates of Tiharjail, Delhi. New Delhi, Vipassana Research Institute: Indian Institute ofTechnology; 2000. http://www.vridhamma.org/Research-on-inmates-of-Tihar-Jail-Delhi
20. Chandiramani K, Verma SK, Dhar PL, and Agarwal N. Psychological effects ofVipassana on Tihar jail inmates: research report. Vipassana Research Institute1995. http://www.vridhamma.org/Psychological-effects-on-tihar-jail-inmates.
Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 Page 16 of 17
21. Newberg AB, Wintering N, Yaden DB, Zhong L, Bowen B, Averick N, et al. Effectof a one-week spiritual retreat on dopamine and serotonin transporterbinding: a preliminary study. Religion, Brain & Behavior. 2017:1–14. https://doi.org/10.1080/2153599X.2016.1267035.
22. Steinhubl SR, Wineinger NE, Patel S, Boeldt DL, Mackellar G, Porter V, et al.Cardiovascular and nervous system changes during meditation. Frontiers inHuman Neuroscience. 2015, 9;(145) https://doi.org/10.3389/fnhum.2015.00145.
23. Conboy LA, Edshteyn I, Garivaltis H. Ayurveda and Panchakarma: measuringthe effects of a holistic health intervention. TheScientificWorldJOURNAL.2009;9:272–80. https://doi.org/10.1100/tsw.2009.35.
24. Kennedy JE, Rosati KG, Spann LH, King AD, Neelon FA, Rosati RA. Changesin spirituality and well-being in a medically based lifestyle program. 2003.http://jeksite.org/research/riceup.pdf
25. Al-Hussaini AA, Dorvlo ASS, Antony SX, Chavan D, Dave J, Purecha V, et al.Vipassana meditation:: A naturalistic, preliminary observation in Muscat.Journal for scientific research Medical sciences / Sultan Qaboos University.2001;3(2):87–92.
26. Gilbert A, Epel E, Tanzi R, Rearden R, Schilf S, Puterman E. A RandomizedTrial Comparing a Brief Meditation Retreat to a Vacation: Effects on DailyWell-Being. The Journal of Alternative and Complementary Medicine. 2014;20(5):A92–A. https://doi.org/10.1089/acm.2014.5242.abstract.
27. Ornish D, Lin J, Chan JM, Epel E, Kemp C, Weidner G, et al. Effect ofcomprehensive lifestyle changes on telomerase activity and telomerelength in men with biopsy-proven low-risk prostate cancer: 5-year follow-upof a descriptive pilot study. The Lancet Oncology. 2013;14(11):1112–20.https://doi.org/10.1016/s1470-2045(13)70366-8.
28. Vella EJ, Budd M. Pilot study: retreat intervention predicts improved qualityof life and reduced psychological distress among breast cancer patients.Complement Ther Clin Pract. 2011;17(4):209–14. https://doi.org/10.1016/j.ctcp.2011.01.005.
29. Garland S, Carlson L, Marr H, Simpson S. Recruitment and retention ofpalliative cancer patients and their partners participating in a longitudinalevaluation of a psychosocial retreat program. Palliative & Supportive Care.2009;7(1):49–56.
30. Kwiatkowski F, Mouret-Reynier MA, Duclos M, Leger-Enreille A, Bridon F,Hahn T, et al. Long term improved quality of life by a 2-week groupphysical and educational intervention shortly after breast cancerchemotherapy completion. Results of the ‘Programme of accompanyingwomen after breast cancer treatment completion in thermal resorts’(PACThe) randomised clinical trial of 251 patients. Eur J Cancer. 2013;49(7):1530–8. https://doi.org/10.1016/j.ejca.2012.12.021.
31. Hadgkiss EJ, Jelinek GA, Weiland TJ, Rumbold G, Mackinlay CA, Gutbrod S,et al. Health-related quality of life outcomes at 1 and 5 years after aresidential retreat promoting lifestyle modification for people with multiplesclerosis. Neurological sciences : official journal of the Italian NeurologicalSociety and of the Italian Society of Clinical Neurophysiology. 2013a;34(2):187–95. https://doi.org/10.1007/s10072-012-0982-4.
32. Beatus J, O'Neill JK, Townsend T, Robrecht K. The effect of a one-weekretreat on self-esteem, quality of life, and functional ability for persons withmultiple sclerosis. J Neurol Phys Ther. 2002;26(3):154–9.
33. Li MP, Jelinek GA, Weiland TJ, Mackinlay CA, Dye S, Gawler I. Effect of aresidential retreat promoting lifestyle modifications on health-related qualityof life in people with multiple sclerosis. Qual Prim Care. 2010;18(6):379–89.
34. Brazier A, Mulkins A, Verhoef M. Evaluating a yogic breathing andmeditation intervention for individuals living with HIV/AIDS. Americanjournal of health promotion : AJHP. 2006;20(3):192–5.
35. Kennedy JE, Abbott RA, Rosenberg BS. Changes in spirituality and well-beingin a retreat program for cardiac patients. Altern Ther Health Med. 2002;8(4):64. -6, 8-70, 2-3
36. Garland S. A pilot project to assess the impact of a psychosocial retreatintervention on the quality of life, distress, marital satisfaction and existentialconcerns in palliative cancer patients and their partners: ProQuestDissertations Publishing; 2007.
37. Froh JJ, Fan J, Emmons RA, Bono G, Huebner ES, Watkins P. Measuringgratitude in youth: assessing the psychometric properties of adult gratitudescales in children and adolescents. Psychol Assess. 2011;23(2):311–24.https://doi.org/10.1037/a0021590.
38. McCullough ME, Emmons RA, Tsang JA. The grateful disposition: aconceptual and empirical topography. J Pers Soc Psychol. 2002;82(1):112–27.
39. Ryff CD, Singer B. Psychological well-being: meaning, measurement, andimplications for psychotherapy research. Psychother Psychosom. 1996;65(1):14–23.
40. Veit CT, Ware JE Jr. The structure of psychological distress and well-being ingeneral populations. J Consult Clin Psychol. 1983;51(5):730–42.
41. Ornish D, Magbanua MJM, Weidner G, Weinberg V, Kemp C, Green C, et al.Changes in prostate gene expression in men undergoing an intensivenutrition and lifestyle intervention. Proc Natl Acad Sci U S A. 2008;105(24):8369–74. https://doi.org/10.1073/pnas.0803080105.
42. Minter SG. Tenneco: pursuing health for the long term. Occupational Hazards.1996;58(4):53.
43. Fries JF, Koop CE, Beadle CE, Cooper PP, England MJ, Greaves RF, et al.Reducing health care costs by reducing the need and demand for medicalservices. N Engl J Med. 1993;329(5):321–5.
44. Wolfe R, Parker D, Napier N. Employee health management and organizationalperformance. J Appl Behav Sci. 1994;30(1):22–42. https://doi.org/10.1177/0021886394301002.
45. Stead BA. Worksite health programs: A significant cost-cutting approach.Business Horizons. 1994 1994/11/01:73–8.
46. Ho JTS. Corporate wellness programmes in Singapore: effect on stress,satisfaction and absenteeism. J Manag Psychol. 1997;12(3):177–89.https://doi.org/10.1108/02683949710174801.
• We accept pre-submission inquiries
• Our selector tool helps you to find the most relevant journal
• We provide round the clock customer support
• Convenient online submission
• Thorough peer review
• Inclusion in PubMed and all major indexing services
• Maximum visibility for your research
Submit your manuscript atwww.biomedcentral.com/submit
Submit your next manuscript to BioMed Central and we will help you at every step:
Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 Page 17 of 17