Makara Human Behavior Studies in Asia Makara Human Behavior Studies in Asia

The federal government of Malaysia recently implemented a nationwide Movement Control Order (MCO) to control the COVID-19 outbreak. However, the MCO has had a negative impact on people’s mental well-being. Interventions that can improve people’s mental health when their movement is restricted are therefore urgently needed. The present study investigated the impact of an ultra-brief online mindfulness-based intervention on mental health using a two-arm randomized controlled trial design. A total of 161 participants self-reported their distress, anxiety, psychological insecurity, and well-being at baseline and post-treatment, while 61 of them answered the same set of measures and the fear of COVID-19 scale in a follow-up study two weeks later. A multivariate analysis of covariance found the intervention reduced psychological insecurity levels measured during post-treatment. Moreover, gender, the experience of practicing mindfulness, and participants’ experiences of undergoing quarantine were found to play a role in post-treatment measures. No significant difference was found between the baseline and follow-up treatment. However, hierarchical multiple regression found that psychological insecurity measured at baseline positively predicted the level of fear after controlling for demographic variables. Overall, the findings suggest that an online mindfulness intervention is a potentially useful tool for alleviating people’s mental health difficulties.


Introduction
The infectious coronavirus disease (COVID-19) caused by a novel coronavirus was first identified amid an outbreak of respiratory illness in Wuhan City, Hubei Province, China.The WHO declared a global health emergency on 30 January 2020.By 11 March 2020, the WHO announced that COVID-19 was a global pandemic.In response to the COVID-19 pandemic, the federal government of Malaysia implemented a Movement Control Order (MCO) as a nationwide preventive measure on 18 March 2020.Since then, civilians have only been allowed to leave their homes under specific circumstances while practicing personal hygiene and social distancing.
Although the MCO plays an important role in containing the spread of COVID-19, prolonged time in isolation on top of the uncertainty of this global pandemic had inevitably had a negative impact on people's mental wellbeing.Since the MCO began, the impact has been reflected in the sharp increase in messages and calls received by the Malaysian Ministry of Health's Psychological First Aid (Mercy Malaysia) hotline as well as support groups like Befrienders (Fong, 2020, para.1).A recent Malaysian study (Azuddin, 2020) discovered that almost half of their respondents faced some forms of negative emotional experience, with 22% having severe to extremely severe anxiety, 20% developing depression, and 15% experiencing alarming levels of stress during this MCO period.However, these statistics merely represent Malaysians' mental health states at the beginning of the MCO.Numbers may escalate as the MCO prolongs and even after the MCO has been lifted.
Consequently, interventions that can improve mental health while restricting movement are urgently needed.One feasible intervention would be mindfulness-based strategies which are widely recommended as a treatment for various types of mental distress (Demarzo et al., 2015).The key advantage of mindfulness interventions is their accessibility, affordability, and sustainability.It is believed that incorporating mindfulness practices during uncertain times such as during an MCO can help people develop healthier coping and distress management skills.Therefore, the present study investigated the effects of an online mindfulness-based intervention on people's mental health issues such as anxiety, psychological insecurity, well-being, and distress during the COVID-19 outbreak in Malaysia.

The Negative Impact of COVID-19 on Mental Health.
The COVID-19 outbreak has had harmful effects both socioeconomically and in well-being.For instance, Yang and Ma (2020) conducted a large-scale nationwide study in China and found that the onset of COVID-19 led to a 74% drop in overall emotional well-being.Similarly, Zhang, Wang, Rauch, and Wei (2020) concluded that adults who did not work during the outbreak had worse mental and physical health as well as poorer life satisfaction.They also found that the severity of COVID-19 in a given locality predicts peoples' life satisfaction.
The Beneficial Effects of Mindfulness.Kabat-Zinn (1994) defined mindfulness as paying non-judgmental attention to the present moment on purpose.Mindfulness emphasizes awareness of internal processes like bodily sensations as well as thoughts and feelings.It encourages one to be attentive to events happening in the moment while letting go of any concerns about the past and future.Therefore, mindfulness is useful for disengaging humans from automatic thoughts, habits, and unhealthy behavior, while enhancing self-regulation and well-being (Ryan & Deci, 2001).Kabat-Zinn et al. (1992) found that his mindfulness training programs were successful at reducing generalized anxiety and panic disorders.Similarly, when examining the efficacy of an acceptance-based behavioral therapy focusing on mindful behavioral engagement for generalized anxiety disorder (GAD), Roemer et al. (2009) found that 78% of treated participants no longer met the criteria for GAD during a post-treatment assessment.Mindfulness helps to reduce anxiety and depression by enabling one to respond to uncertainties with awareness instead of reacting instinctively (Hofman, Sawyer, Witt, & Oh, 2010;Jacobs & Blustein, 2008).
Apart from reducing distress, mindfulness related practices are also associated with improved life satisfaction, positive affect, and positive mental health (Kong, Wang, & Zhao, 2014;Shier & Graham, 2011).To illustrate, Ding, Tang, Tang, and Posner (2014) found mindfulness training had multiple positive effects on psychological well-being including improved self-control, enhanced positive emotions, and even decreased negative emotions and lowered stress hormones.The RAIN protocol is an ultra-brief four-step distress transformation protocol originally designed by Michele McDonald (Brach, 2020).The RAIN protocol consists of four steps: (R) recognize what is going on (e.g., distressing feelings); (A) allow the experience to be in a non-judgmental manner; (I) investigate with kindness (e.g., how has this distress developed); and (N) non-identifying which promotes de-fusion between the individual and their distress.Most recently, Hedderman et al. (2020) proposed the RAIN protocol as part of a comprehensive mindfulness-based intervention for mitigating the risks of psychological distress and burnout in healthcare workers during the COVID-19 pandemic.Based on past studies, this study hypothesized that the ultra-brief online mindfulness intervention would reduce distress (H1), anxiety (H2), psychological insecurity (H3), enhance well-being (H4), and reduce the fear of COVID-19 (H5).

Methods
Participants and Design.This study utilized a two-arm randomized controlled trial design to assess the effects of an online mindfulness intervention on mental health.Participants answered the survey before the treatment (baseline), after the treatment (post-treatment), and during the optional two-week follow-up study (follow-up treatment).
A total of 235 cases were recorded using an online survey system.However, 49 cases were removed for not completing the baseline measures resulting in 186 cases.Among them, 25 cases (13.44%) were removed for not completing the manipulation or the post-treatment measures.Therefore, the final sample for analysis consisted of 161 individuals (119 females and 42 males) with a mean age of 28.75 (SD = 9.01, ranging from 18 to 70 years old).The majority of the sample were Chinese (80.7%) followed by Indians (11.2%),Malays (6.2%), and others (1.9%).More than half of the participants identified themselves as worshippers of Buddhism (57.76%) followed by Christianity (20.50%),Islam (8.70%), others (8.07%), and Hinduism (4.97%).
Other items revealed that 157 (97.5%) of participants were Malaysians (2.5% were foreigners) of which 20 (12.4%) of them had continued working during the MCO, 51 (31.7%) of them had practiced mindfulness before the MCO, while 1 (0.62%) of them had been tested for COVID-19, and 16 (9.9%)had been either instructed to participate in home surveillance or quarantine.None of the participants had been diagnosed with COVID-19.
The participants were invited to join a follow-up study in the following two weeks.In total, 61 participants (retention rate = 37.89%, 44 females and 17 males, 33 from the treatment group and 28 from the control group) answered the follow-up-treatment measures.Figure 1 shows a consort diagram.

Study Intervention RAIN: Ultra-Brief Mindfulness-based Intervention.
We adapted and contextualized the original RAIN protocol to the local pandemic-induced lockdown situation, by using complementary short journaling prompts that engaged participants in self-reflection.Journaling is known as a creative way to engage people in a therapeutic activity that promotes self-awareness (Utley & Garza, 2011).Creating a visual narration of thoughts, feelings, and experiences helps individuals make internal experiences more tangible and manageable, especially during such uncertain times.
The first step of the protocol involved asking participants to recognize distressing cognitive and affective experiences associated with the COVID-19-induced lockdown.Second, participants were asked to learn to practice radical acceptance of their distress.Third, participants are asked to identify strengths, opportunities, and blessings that they may have encountered during this pandemic crisis.Finally, participants were invited to generate adaptive behavioral strategies to cope with the inconveniences that they were experiencing.
In the present study, participants in the treatment group were asked to indicate a) their present feelings about the MCO, b) three things they could do to make themselves feel better, c) three privileges/benefits they encountered during the MCO, and d) three things they could do for themselves and others during the MCO.Similarly, the control group was asked to answer another four questions indicating a) their feelings about the current COVID-19 situation, b) three actions they were taking to prevent COVID-19, c) three ways they obtained news about COVID-19 during the MCO, and d) three things they wished to do after the MCO had been lifted.See Appendix b for the scripts used in the treatment and control groups.

Measures
Subjective Unit of Distress Scale.The Subjective Unit of Distress Scale is a classic 10-point scale used to assess the intensity of subjective distress experienced by an individual at the present moment (Wolpe, 1973).It is commonly used by therapists as an indication of the progress of therapy.In the present study, participants were assessed on a 10-point scale (i.e., 1: Feeling great; 10: I am exploding out of control).A sample question was "How do you feel right now?".Participants rated their subjective experience of distress on a sliding scale during the pre-and post-test.
Anxiety.Participants' anxiety levels were assessed using the Generalized Anxiety Disorder scale (GAD-7; Spitzer, Kroenke, Williams & Löwe, 2006).The GAD-7 consists of seven items rated on a 4-point Likert scale ranging from 0: Not at all; 1: Several days; 2: More than half of the days; to 3: Nearly every day.The total score is calculated by summing up the seven items (the score ranges from 0 to 21).An example of an item was "Being so restless that it is hard to sit still".Spitzer et al. (2006) demonstrated that the GAD-7 had good reliability, as well as a good criterion, construct, factorial, and procedural validity.

Enrollment
Psychological Insecurity.The 10-item Psychological Insecurity Scale constructed by Taormina and Sun (2015) was adapted for the present study.Items were modified to assess psychological insecurity about COVID-19 experienced during the MCO (see Appendix a).For example, the item "I emotionally troubled by the suffering of other people" was revised to "I am emotionally troubled by the reports of the COVID-19 cases".Using a 5point Likert scale (1: Strongly disagree; 5: Strongly agree), respondents self-reported their level of insecurity.After reverse scoring item 2, the average score of the 10 items was computed.Individuals who reported a higher score experienced a higher level of insecurity.
General Well-Being.Participants' general well-being was assessed using the World Health Organization-Five Well-Being Index (WHO-5; WHO, 1998).This is a short selfreported measure of mental well-being in relation to conditions experienced over the past two weeks.The scale consists of five items rated on a 6-point Likert scale from 0 (At no time) to 5 (All of the time).The total raw score is calculated by summing up the five items (scores range from 0 to 25).The final score was the raw score multiplied by 4, with 0 representing the worst imaginable well-being and 100 representing the best imaginable well-being.An example of an item is "I have felt cheerful and in good spirits".Prior to the present study, item response theory analyses in studies with both younger and elderly populations had indicated good construct validity for the WHO-5 as a unidimensional well-being measurement scale (Topp, Østergaard, Søndergaard, & Bech, 2015).(Ahorsu et al., 2020).This scale consists of seven items assessing participants' fear of COVID-19.Respondents indicated the extent of their agreement with each item using a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree) to selfreport their fear of COVID-19.Individuals who reported a higher total score were assumed to have a greater fear of COVID-19.An example item is, "I cannot sleep because I'm worried about getting Corona."

Fear of COVID-19 Scale
Other Variables.Several demographic and background variables that may have influenced the outcome variables were also measured and included in the analysis to statistically control for their impacts.The variables were age, gender (0: female, 1: male), number of days of experiencing MCO ("days"), whether participants continued working during the MCO ("working"; 0: no, 1: yes), whether participants had an experience of practicing mindfulness before the MCO (0: no, 1: yes), whether participants had been tested for COVID-19 ("Testing"; 0: no, 1: yes), and whether participants had been instructed to undertake home surveillance or any form of quarantine for COVID-19 ("Quarantine"; 0: no, 1: yes).
Procedures.The present study was reviewed and approved by the Scientific and Ethical Review Committee of Universiti Tunku Abdul Rahman (ref.no: U/SERC/62/2020), as well as registered with ClinicalTrials.gov(NCT04536441).Participants were recruited using convenience sampling and snowball sampling.An online survey was created, and the survey URL was posted on the authors' social networking sites to recruit respondents.
After giving their consent, participants answered questions about their demographic and background information followed by the first measures (i.e., baseline) of distress, anxiety, psychological insecurity, and wellbeing.Then, half of the participants were randomly assigned to the mindfulness intervention condition (i.e., treatment group) and the others were assigned to the control group.The treatment group answered four questions about the mindfulness intervention while the control group answered another four questions.After that, all participants answered the second set of measures (i.e., post-treatment) about distress, anxiety, psychological insecurity, and well-being.Finally, participants were informed about and invited to join the follow-up study in two weeks' time.Interested individuals provided their email addresses so that researchers could send them invitations and the survey link.Helpline numbers for counseling services (provided by the Ministry of Women, Family and Community Development) were also given to all participants before they exited the survey.
During the follow-up study, participants answered the third set of measures about distress, anxiety, psychological insecurity, and well-being, as well as their fear of COVID-19.

Data Analysis Plan.
In the present study, we analyzed all cases that completed at least baseline, allocated intervention, and post-test measures.Pearson correlation analysis was conducted to investigate the relationships between variables, while the reliability of measurements was examined using the Cronbach alpha coefficient.Then, two multivariate analyses of covariates (MANCOVAs) were conducted to examine the effectiveness of the ultrabrief online mindfulness intervention.In the first MANCOVA, the group condition (treatment vs. control) was treated as an independent variable and the four target variables (i.e., distress, anxiety, psychological insecurity, and well-being) measured post-treatment were included as dependent variables.Moreover, demographic and background variables (i.e., age, gender, days, working, mindfulness experience, testing, quarantine), and the four target variables measured at baseline were entered as covariate variables.
The second MANCOVA was conducted to examine the impact of the mindfulness intervention two-weeks' later at the follow-up.Similarly, the group condition served as an independent variable alongside the four target variables measured at follow-up, with treatment and the fear of COVID-19 as dependent variables.The covariate variables were age, gender, days, working, mindfulness experience, testing, quarantine, and the four target variables were measured both pre-and post-treatment.
Furthermore, a hierarchical multiple regression was conducted to examine variables (measured at baseline) that had effects on the of COVID-19 (measured at followup treatment).Demographic variables such as age, gender, days, working, mindfulness experience, and quarantine were first entered into Step 1, while the four target variables (measured at baseline) were entered into Step 2.
For the sake of clarity, we only reported statistically significant results for the abovementioned analyses.

Results
Table 1 presents the descriptive statistics, intercorrelations, and Cronbach alpha coefficients for the measured variables.All measurements indicated good internal consistency.Moreover, there was a significant relationship between all the variables except the fear of COVID-19 measured during follow-up treatment.A similar pattern was observed across the three waves.For instance, wellbeing was negatively associated with distress, anxiety, and psychological insecurity, while psychological insecurity was positively associated with distress, anxiety, and the fear of COVID-19.
Table 2 shows the summary of MANCOVA for betweensubjects effects.Results indicated that group condition (treatment vs. control) had a significant effect on psychological insecurity only measured at post-treatment (p = 0.041).Specifically, the treatment group reported significantly lower scores than the control group.An inspection of distress measured post-treatment found that quarantine (p = 0.045) had a significant effect, as well as distress (p < 0.001), psychological insecurity (p = 0.018), and well-being (p = 0.029) measured at baseline.On the other hand, both anxiety (p < 0.001) and psychological insecurity (p = 0.001) measured at baseline had a significant effect on post-treatment anxiety.Moreover, mindfulness experience (p = 0.009), testing (p = 0.041), quarantine (p = 0.029), and psychological insecurity measured at baseline (p < 0.001) were found to have a significant effect on post-treatment psychological insecurity.Finally, gender (p = 0.036), mindfulness experience (p = 0.022), psychological insecurity (p =0.038), and well-being (p < 0.001) measured at baseline had a significant effect on post-treatment well-being.The second MANCOVA compared the scores measured at follow-up treatment.The background variable 'testing' was excluded because none of the respondents were tested for COVID-19.No significant effect was found in the multivariate tests.Tests for between-subjects effects (see Table 3) showed that distress (measured at followup treatment) was influenced by quarantine (p = .041).
Taken together, the MANCOVA results suggested that the ultra-brief online mindfulness intervention was effective at reducing psychological insecurity right after the treatment.The effect, however, did not last for two weeks.The intervention did not have an impact on distress, anxiety, and well-being respectively.

Discussion
This research explored the use of an ultra-brief mindfulness-based intervention during the COVID-19 pandemic-induced lockdown period to assess people's mental health.The online intervention was developed due to the unprecedented social distancing measures across the globe.We examined the immediate and longer-term effects of the ultra-brief mindfulness-based intervention (RAIN) on subjective units of distress, anxiety, psychological insecurity, and well-being among people in Malaysia.Our primary finding was that despite the brevity of the intervention, participants in the treatment group demonstrated statistically significant lower levels of psychological insecurity than their control group counterparts.In addition, our study found that psychological insecurity measured at baseline predicted the fear of COVID-19 measured during follow-up.
Thus far, previous studies have reported negative impacts of psychological security on well-being (De, Roy, Rashid, & Banik., 2018) and depression (Li et al., 2018).Importantly, our results suggest that the online ultra-brief mindfulness-based intervention is a promising tool for alleviating psychological insecurity in the short term.This result may be explained by the fact that the RAIN protocol emphasizes both mindfulness and the acceptance of difficult emotions.Other studies have found that these key elements of the intervention have reduced psychological symptoms following the exposure to actual critical incidents (Shipherd & Salters-Pedneault, 2018) as well as laboratory-induced worry (Ainsworth, Bolderston, & Garner, 2017).
Nevertheless, the difference in psychological insecurity between the treatment and control groups was no longer evident during follow-up, implying that the therapeutic benefits of ultra-brief mindfulness-based intervention may not be persistent.This finding contrasts with recent studies that have suggested that the ultra-brief mindfulness-based intervention can have long-lasting effects (Bloom-Foster & Mehl-Madrona, 2020;Shuai, Bakou, Hardy, & Hogarth, 2020).Instead, our finding supports observations in Elefant, Contreras, Muñoz, Bunge, and Leykin, (2017) indicating that ultra-brief interventions often have immediate effects, but no lasting benefits.Despite these short-lived effects, our results suggest the baseline level of psychological insecurity significantly influenced the fear of COVID-19 measured during a two-week follow-up, while participants reported a lower level of psychological insecurity after receiving the treatment.Taken together, these findings suggest the potential of the ultra-brief online intervention to reduce psychological insecurity that may in turn relieve the fear of COVID-19.This mechanism warrants further investigation.Furthermore, previous experience of mindfulness practice was a significant protective factor against distress, anxiety, psychological insecurity, and well-being at baseline.These findings corroborate the overwhelming meta-analytic evidence of the benefits of mindfulness training against various mental health problems across the lifespan (Borquist-Conlon et al., 2019;Li & Bressington, 2019).
Contrary to expectations, this study did not find that the RAIN intervention had any significant effect on anxiety, subjective units of distress, and well-being.Recently, the beneficial effects of mobile app-based mindfulness interventions have been supported by meta-analytic evidence (Linardon, 2019).While online and/or mobilebased mindfulness interventions are viable, we argue that prolonged mindfulness training may be necessary for greater and more sustained psychological benefits.
There were several limitations to the present study.First, participants were recruited from various channels of social media (e.g.Facebook, WhatsApp, Telegram, etc.)While this population represents the intended audience (who has access to the Internet) of the intervention designed, the results may not be generalizable to other recruitment strategies.In addition, the high attrition rates in our study, especially at the two-week follow-up, precluded an indisputable determination regarding the longer-term effectiveness of our intervention.Finally, some items of the psychological insecurity scale were modified to fit the scope of the present study.Unfortunately, the current sample was inadequate for testing the scale's factorial structure.Nevertheless, the scale showed good internal consistency.Moreover, its theoretical relationship with measurements of distress, anxiety, and well-being was duly supported.
Study.Mindfulness was expected to buffer the negative emotional consequences of the COVID-19 pandemic.Indeed, several studies (Behan, 2020; Hedderman, O'Doherty, & O'Connor, 2020; Jiang et al., 2020) have established empirical evidence of the positive effects of mindfulness.The present study went beyond those studies by investigating the effectiveness of an ultra-brief online mindfulness intervention (based on the RAIN protocol) on people's mental health in Malaysia.

Figure 1 .
Figure 1.CONSORT 2010 Flow Diagram correlation matrix of baseline and post-treatment shows the relationship between the variables measured at the same wave, except for the fear of COVID-19.M = mean; SD = standard deviation; Alpha = Cronbach alpha coefficient; Insecurity = psychological insecurity; WB = well-being; Fear = fear of the COVID-19 measured at follow-up treatment.* p < 0.05, ** p < 0.01, *** p < 0.001 Note.N = 161.Insecurity_Post = psychological insecurity measured at post-treatment; WB_Post = well-being measured at posttreatment, Days = number of days of experiencing movement control order (MCO); Working = continued working during the MCO; Mind_Exp = experience of practicing mindfulness before the MCO; Testing = tested for the COVID-19; Quarantine = instructed to undertake home surveillance or any form of quarantine for COVID-19; Insecurity_Base = psychological insecurity measured at baseline; WB_Base = well-being measured at baseline; Condition = treatment group vs. control group.* p < 0.05, ** p < 0.01, *** p < 0.001

Note.
The analysis was based on 36 cases with complete data collected at baseline, post-treatment, and follow-up treatment.Insecurity_Follow = psychological insecurity measured at follow-up treatment; WB_Follow = well-being measured at follow-up treatment, Fear = fear of COVID-19; Days = number of days of experiencing movement control order (MCO); Working = continued working during the MCO; Mind_Exp = experience of practicing mindfulness before the MCO; Testing = tested for the COVID-19; Quarantine = instructed to undertake home surveillance or any form of quarantine for COVID-19; Insecurity_Base = psychological insecurity measured at baseline; WB_Base = well-being measured at baseline; Insecurity_Post = psychological insecurity measured at post-treatment; WB_Post = well-being measured at post-treatment; Condition = treatment group vs. control group.*p < 0.05, ** p < 0.01, *** p < 0.001