Taking a holistic approach to care

Institute for Integrative Healthcare and Health Promotion (IGVF)

Non-communicable diseases such as type 2 diabetes mellitus, cardiovascular disease and cancer are regarded as one of the greatest challenges facing global health systems in the 21st century. In particular, the prevalence of diabetes mellitus has risen significantly in recent years, with type 2 diabetes accounting for around 90 per cent of cases. Despite the availability of effective medical treatment options, many people with the condition do not achieve adequate metabolic control, which means that the risk of complications remains high. Alongside well-known somatic risk factors, psychosocial factors are increasingly becoming the focus of research. Studies show that psychological distress, negative emotional states and chronic stress can have adverse effects on treatment adherence, self-management and disease progression. At the same time, it is suggested that emotion regulation skills may have a potentially protective influence on diabetes-related outcomes.

As part of this PhD project, we will investigate whether, and in what ways, emotion regulation is associated with type 2 diabetes. To this end, a scoping review will be conducted to systematically review the current state of research and identify research gaps. Building on these findings, the PhD project will also include an interview-based study with people living with the condition. The aim is to identify and categorise, in a theory-guided manner, aspects of emotion regulation in people with type 2 diabetes. We hope to gain insights that can contribute to improving quality of life and expanding treatment options for type 2 diabetes.

Non-communicable diseases such as type 2 diabetes mellitus, cardiovascular disease and cancer are regarded as the greatest challenge facing global health systems in the 21st century. Despite numerous measures aimed at the prevention and treatment of these diet- and lifestyle-related diseases, their prevalence is on the rise. Studies on interventions that focus on a healthy lifestyle have so far mainly examined the short-term impact on health behaviour, whilst the long-term effects are often overlooked. Among the measures currently under active discussion as suitable for bringing about long-term changes in health behaviour is the strengthening of self-regulation through mindfulness (e.g. mindful eating), as this can have a positive impact on health behaviour and improve the self-management of chronic conditions as well as mental and physical health.

Within the framework of this research project, the aim is therefore first to investigate whether and how citizens’ health behaviours could be improved through an intensive lifestyle intervention. The focus is on the evaluation of social-cognitive parameters relating to self-efficacy, action planning and outcome expectations. The participants in a controlled, non-randomised intervention study (Healthy Lifestyle Community Programme; HLCP) conducted at a local authority level serve as the target group for the study. Follow-up surveys will examine the long-term effect of the health promotion measure on health behaviour (approximately 5 years after the intensive lifestyle intervention). Building on the HLCP, a follow-up intervention aimed at behavioural change, with a focus on self-regulation and mindfulness, will be carried out and subsequently evaluated.

The research project is being carried out in collaboration with Münster University of Applied Sciences.

For further information on the PhD project, please contact: carmen.kettler@fh-muenster.de.

The natural menstrual cycle influences numerous physical, psychological and behavioural processes, such as sleep, eating habits, stress levels, the immune response and the frequency of physical activity. It stands to reason that there is also a link to motivation for health-promoting behaviours. This is particularly significant against the backdrop of the rapid rise in chronic conditions associated with an unhealthy lifestyle. How do people manage to make time for positive health-promoting behaviours? What role does the natural menstrual cycle play in this?

We would like to explore these questions as part of a mixed-methods research project and investigate the extent to which monthly fluctuations in hormone levels within the natural menstrual cycle are linked to meditation in everyday life and the motivation to practise it. To capture as broad a spectrum as possible, the study will include both long-term meditators and people with little or no meditation experience who practise guided meditation using the 7Mind app. In addition, qualitative (in-depth) interviews will be combined with quantitative questionnaire surveys (including a randomised controlled trial) to enable a nuanced investigation of potential behavioural and resource-related correlations.

Further details on the study project can be found here, or please feel free to contact the PhD students by email at martha.koelman@uni-wh.de and lisa.siering@uni-wh.de.

A sense of connectedness – the subjective feeling of belonging and being cared for (Michaelsen, 2021) – has direct positive effects on health in the areas of mental and physical well-being, for example on immune function, cognitive function, ageing and mortality (Esch/Stefano/Michaelsen, 2024). A sense of connectedness can be fostered as a health resource through mind-body medical interventions (ibid.).

This doctoral project examines connectedness using a mixed-methods approach as a subjective, health-promoting resource and aims to identify the factors that foster the experience of connectedness.

As a cumulative PhD, this project consists of two parts: The first part, as a qualitative sub-study of ‘The Art of Listening’ (KdZ), focuses on the exploratory investigation of a moment of connectedness whilst narrating to a person trained in non-judgemental listening within a ‘listening room’.

The second part utilises findings from the ‘Mindfulness and Connectedness’ (A&V) project, in which individuals with at least three years’ meditation experience were assessed using various scales measuring mindfulness (FFMQ-D), self-transcendence (ASTI), compassion (CLS), self-efficacy (SWE) and connectedness (WCS, CSC). In this part, the new, multidimensional scale for measuring connectedness – the Connectedness Coordinate System (CSC) – is validated and presented among long-term meditators. Furthermore, the Watts Connectedness Scale (WCS) is validated.

Behavioural therapy-supported smoking cessation using e-cigarettes

According to the Federal Ministry of Health, smoking is the greatest preventable health risk in Germany and incurs high costs for both individuals and society as a whole. According to the latest findings from the German Survey on Smoking Behaviour (DEBRA) from November 2022, 36 per cent of Germans smoke cigarettes or use tobacco in other forms.

Although a large proportion of smokers are motivated to give up smoking, many of them find it difficult to achieve and maintain this goal. Guideline-compliant smoking cessation interventions are rarely used and are associated with low adherence and low success rates. New, innovative approaches are needed to help smokers quit smoking permanently.

This PhD project aims to develop and evaluate a digital smoking cessation intervention. The intervention integrates an app-based behavioural intervention with e-cigarette-assisted nicotine withdrawal, thereby addressing both the physical and psychological aspects of cigarette addiction.

The behavioural intervention is based on the ‘BERN – Healthy under Stress’ health promotion course developed by Prof. Esch (2013) for multimodal stress reduction and health promotion. The course content has been partially modified and expanded for the population of smokers and, in addition to information and exercises on stress-reducing behaviours, relaxation, exercise, enjoyment and nutrition, as well as modules developed specifically for smokers that explain the mechanisms of cigarette dependence and prepare them for the difficulties they can expect when giving up smoking. Effective stress management is a key focus of the intervention, given the scientifically established link between smoking and stress.

A feasibility study and a randomised controlled trial are planned to evaluate the programme’s effectiveness and efficacy. As part of these studies, the user-friendliness, feasibility and effectiveness of the described intervention will be compared with a ‘treatment-as-usual’ control group. It is hoped that the findings will help to support smokers in making a sustainable lifestyle change.

Background

High levels of stress among nursing staff in hospitals have a negative impact on both staff and the quality of healthcare. The aim of these studies was to investigate the effectiveness of a digitally supported mindfulness intervention (d-MI) among nursing staff in acute inpatient care. The intervention aims to improve perceived stress levels and other work- and health-related outcomes.

Methods

Two randomised controlled trials were conducted in North Rhine-Westphalia: one single-centre and one multi-centre trial (4 hospitals). The single-centre study involved nursing staff only, whereas the multi-centre study was open to both nursing staff and nursing trainees. The intervention groups (IG) received a d-MI consisting of an app (access for 1 year), two web-based workshops (offered within the first 2.5 months) and a workbook, whilst the waiting-list control groups (WLC) received the same intervention 2.5 months later. Study participants were surveyed via an online questionnaire at the start of the study and again after 2.5 months, 5.5 months and 8.5 months. The questionnaire covered perceived stress (PSS-10; primary outcome), work- and health-related outcomes, acceptance, usage behaviour, and socio-demographic and work-related characteristics.

Further information on both studies

German Register for Clinical Trials: DRKS00024937 (single-centre study) and DRKS00025997 (multi-centre study)

Study protocol for the multicentre study: Schönfeld, S., Rathmer, I., Michaelsen, M. M., Hoetger, C., Onescheit, M., Lange, S., Werdecker, L. & Esch, T. (2022). Effects of a Mindfulness Intervention Comprising an App, Web-Based Workshops, and a Workbook on Perceived Stress Among Nurses and Nursing Trainees: Protocol for a Randomised Controlled Trial. JMIR Research Protocols, 11(8), e37195. doi.org/10.2196/37195

For further details regarding the study, please feel free to contact the PhD student simone.schoenfeld@uni-wh.de by email.

Related research projects

Mindfulness in acute inpatient care – a single-centre randomised controlled trial

Funded by: BARMER

Duration: February 2021 to September 2022

Mindfulness in acute inpatient care – a multicentre randomised controlled trial

Funded by: BARMER

Duration: February 2021 to September 2022

Mindfulness in acute inpatient care – an exploratory analysis of two randomised controlled trials

Funded by: BARMER

Duration: November 2022 to May 2023

Dental anxiety is associated with avoidance of treatment, a reduced quality of life in relation to oral health, and increased rates of complications during dental treatment. Mindfulness can help to improve attention and emotional regulation and could therefore potentially reduce dental anxiety. This study investigates the effects of an app-based mindfulness intervention on dental anxiety in patients prior to dental surgery. We are using a mixed-methods design comprising a randomised controlled trial (RCT) and semi-structured interviews. As part of the RCT, 100 dental patients will be randomised to either an app-based mindfulness training programme or a control group. Data will be collected before the start of the intervention (T0), after completion of the intervention and before surgery (T1), and postoperatively (T2). The primary endpoint is dental anxiety. Secondary endpoints include general anxiety, perceived stress, positive and negative affect, mindfulness, and post-operative pain. In addition, guided interviews will be conducted with 15–20 participants from the intervention group and analysed qualitatively. It is expected that, compared with the control group, the intervention group will show significantly greater improvements in terms of both the primary and secondary endpoints at T1 and T2. The results could contribute to the implementation of cost-effective measures in dental care to sustainably reduce the burden of anxiety and stress for patients and dental practitioners.

Work has long since ceased to be solely a means of earning a living and thus of securing one’s livelihood. Rather, what matters to us as human beings is feeling needed, contributing to the success of a company, or having the sense that we are doing something meaningful. When this is the case and work is experienced as meaningful, it can be a valuable resource for good health. If this experience is lacking, it can increase the risk of developing illnesses.

This doctoral project therefore explores the question of how employees can experience a sense of meaning in the workplace. The focus is on a target group that has received little attention in academic research to date: university professors.

Research shows that this professional group faces high job demands. This raises the question of how professors can carry out their work in a way that is both healthy and productive, and what role the experience of meaning plays in their professional activities.

Of particular interest here is, on the one hand, how a sense of meaning arises and which sources of meaning can be identified, and, on the other hand, how the experience of meaning relates to work- and health-related outcomes.

The aim of the study is to identify potential starting points that can be taken into account when designing university-specific frameworks within the context of health-promoting organisational development.

What health-promoting resources does a mindfulness training course for educators provide – and how exactly does it do so?

Interest in mindfulness is demonstrably high and has made its way into the workplace. In the education sector, too, the popularity of mindfulness is evident in the ever-increasing demand for further training and trainers in this field. The positive physical and mental effects of mindfulness range from stress reduction, emotional regulation, cardiovascular improvements and the ability to concentrate to the enhancement of interpersonal relationships. This is of particular interest to educators, who have been facing significant health challenges long before the pandemic began.

In general, it is already well established that health-promoting interventions, such as mindfulness training, have positive mental and physical effects and can change health behaviours. However, exactly how these effects are brought about, and which techniques and mechanisms underpin these interventions, has yet to be fully researched and understood.

Through the ‘AmSel’ mindfulness training programme for educators in the education sector, we aim to get to the bottom of this question. The ‘AmSel’ training programme stands for ‘Mindfulness- and Compassion-Based Addiction Prevention in Schools’ and covers theoretical content on mindfulness, stress and addiction research, whilst also incorporating a significant amount of self-awareness exercises (physical and perceptual exercises). The aim of the training is for the content to be integrated into everyday school life and passed on to the children.

In our analysis, we draw on the Behaviour Change Resource Model (BCRM) developed by Michaelsen and Esch, which provides a theoretical description of how behavioural change takes place. The model explains the resources that support behavioural change and describes how behavioural change techniques promote these. Using a mixed-methods design, we conduct qualitative research in the form of interviews and, in accordance with the BCRM, investigate which health-related resources among the participants are strengthened (boosting), provided from outside (facilitating) or activated through incentives (nudging) as a result of the training programme. Using questionnaires, we are conducting a quantitative analysis to examine how certain resources among educators change over the course of the continuing professional development programme and how they are interrelated.

Our research can help ensure that health interventions become comprehensible and can be used in a targeted manner in future, thereby facilitating their integration into, for example, the education system.

For further details on the study, please feel free to contact the PhD student anne.wunderlich@charite.de by email.

The doctoral thesis “Qualitative Survey of Medical Practitioners on Peak Moments in General Practice: Their existence and conditions in doctor–patient interactions, as well as possible effects on job satisfaction’ is based on a study in which, using qualitative content analysis according to Kuckartz, interviews on the topic of ‘Peak Moments in General Practice’ were conducted, recorded, transcribed and analysed. For this purpose, 17 semi-structured guided interviews were conducted with GPs working in GP cooperative practices and private practices.

Participants were recruited using purposive sampling. The topics of the interviews related to the prerequisites and conditions for patients to experience ‘Peak Moments’, the characteristics of ‘Peak Moments’, and the potential impact of ‘Peak Moments’ witnessed in patients on the doctors’ job satisfaction. The background to the study was that a trusting relationship and effective communication between doctors and patients influence the success of treatment for patients and are regarded as an important resource for increasing doctors’ job satisfaction. Job satisfaction among GPs, in turn, leads to high-quality medical care and measurable patient satisfaction.

The participants confirmed the existence of ‘Peak Moments’ among patients. The results suggest that communication strategies and intervention measures help to create a situation in which ‘peak moments’ become possible. Specific conditions on the part of both doctors and patients were necessary for patients to experience or bring about a ‘peak moment’.

In the participants’ view, experiencing a Peak Moment led to patients feeling more relaxed and strengthened the relationship of trust between doctors and patients. The effects of patients experiencing a peak moment were assessed by the doctors as positive and meaningful. The Peak Moments experienced contributed to job satisfaction. The results of the qualitative study highlight the need for further studies that utilise quantitative measurement tools for verification.

Part of the doctoral thesis was published in the following article: Jacobs A, Flägel K, Werdecker L, Esch T: Peak moments in doctor–patient interactions in general practice – a qualitative study with general practitioners in Germany. Journal of Evidence, Continuing Education and Quality in Healthcare (ZEFQ) 2022; 172: 31–39. DOI: 10.1016/j.zefq.2022.04.028e

What makes people happy and content at different stages of their lives? And are happiness and contentment actually the same thing? Throughout one’s entire life?

Happiness research generally regards happiness as a static construct, and then uses studies to empirically determine the influence of a wide variety of life circumstances on this construct. Our project examines this assumption and, using quantitative and qualitative methods, investigates the extent to which what we regard as ‘a happy and contented life’ is subject to change over the course of a lifetime. A key focus is the question of what impact major life-altering events (e.g. illness or accident-related disabilities) can have on our perceived happiness.

We hope that the project will yield insights which may extend beyond the boundaries of happiness research and could also be relevant to issues of health and social policy, as well as to health research in general.

Participation

The participant survey was conducted anonymously online and was open to anyone aged 18 or over living in Germany, provided they did not have any cognitive impairments (e.g. dementia).

There is hardly any other public debate in which public opinion is as uniformly aligned as that concerning the need to maintain public safety and order. Police officers are regularly exposed to high levels of physical and psychological stress, which is reflected in their state of health and their experience of health and stress.

To date, the occupational group of young police officers has received little scientific attention.

The aim is to describe the health status of this occupational group and to empirically determine the effects of a yoga programme on cardiovascular risk factors and perceived stress. The focus here is specifically on police officers in training as the target group.

The planned study aims to identify aspects of health promotion and primary and secondary prevention among young adults in a stress-inducing workplace, and to develop a holistic approach to health promotion and prevention.

Is the bio-psycho-social model currently in use sufficient to describe the pathogenesis of burnout holistically, or is a paradigm shift required? We are investigating this.

Burnout, which has been officially included in the WHO’s ICD-11, will in future be attributed to (chronic) stress at work and thus externalised as a stress-related phenomenon. Based on the bio-psycho-social model currently in use, most studies on burnout have focused on investigating biological, psychological and social risk factors, although endogenous factors such as spirituality and culture may also play an important role in stress management.

Our project therefore addresses a central question: alongside bio-psycho-social factors, what role do spirituality (meaning and faith) and culture (a sense of belonging in the working environment) play in relation to burnout in the workplace?

Building on this question, we are investigating whether the perceived meaningfulness of one’s work and the perceived sense of belonging in the working environment influence the risk of burnout among working people and may thus contribute to the onset of the condition or to the maintenance of good health.

The anonymous quantitative data collection took the form of a cross-sectional study conducted via social media channels, as well as in psychotherapy practices, medical care centres and an interdisciplinary clinic for psychosomatics and psychiatry. In addition, a literature review was conducted in online databases to identify relevant studies from the past four decades concerning factors associated with burnout and to map them to the dimensions of the bio-psycho-socio-spiritual-cultural model.

For further information on the study, please contact Ian.Listopad@uni-wh.de by email.

The doctoral thesis by Dr. rer. oec. Dr. rer. medic. Maren M. Michaelsen, entitled ‘Theoretical Analysis of the Functional Mechanisms of Behaviour Change Techniques’, addresses the growing interest in changes to health-related behaviour in light of the rise in lifestyle-related diseases worldwide.

Previous studies have identified numerous resources for behavioural change; however, neurobiological motivation and reward mechanisms (MBn), as automatic, implicit aspects of behaviour, have been largely neglected. The main aim of the thesis is to provide a model-based representation of the role of MBn in behaviour change processes, specifically in the context of health behaviour among various target groups.

By integrating neuroscientific findings into an integrative and conceptual review, a flexible seven-stage process of behavioural change is presented, linking MBn to each stage. The results lead to the categorisation of resources into external, internal reflective and internal affective resources. This enables the classification of behaviour change techniques into ‘facilitating’, ‘boosting’ and ‘nudging’, from which the Behaviour Change Resource Model is derived, presented and discussed.

The discussion emphasises the applicability of this model to the development of interventions aimed at promoting engagement and empowerment in health behaviour. The two publications comprising the cumulative doctoral thesis are:

• Michaelsen, M. M. & Esch, T. (2021). Motivation and reward mechanisms in health behaviour change processes. Brain Research, 1757, 147309. doi.org/10.1016/j.brainres.2021.147309
• Michaelsen, M. M. & Esch, T. (2022). Functional Mechanisms of Health Behaviour Change Techniques: A Conceptual Review. Frontiers in Psychology, 13, 725644. doi.org/10.3389/fpsyg.2022.725644