Feasibility Study of a Compassionate Mindful Resilience (CMR) Intervention to Improve Mental Health Well-being Outcomes Among Youth in Thailand
Phase: NA
Conditions: Mental Health Well-being, Emotional Regulation, Psychological Resilience, Substance Use Prevention
Sponsor: Queen's University, Belfast

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Feasibility study of a Compassionate Mindful 
Resilience (CMR) Intervention to improve 
mental well-being outcomes among youth in 
Thailand  
 
 
Overview of the study 
Phase 1: A scoping review was completed in March 2025, utilising five databases 
(Cochrane, PubMed, Web of Science, APA PsycArticles, and APA PsycINFO) to 
identify studies on Mindfulness-Based Interventions (MBIs) for improving the mental 
health and well-being of adolescents with substance use issues. The review will report 
on how interventions are conducted, and data will be extracted to create baseline 
knowledge and identify research gaps for the development of an intervention to be 
proposed.  
Phase 2: This phase will entail Patient and Public Involvement (PPI) activities, where 
young people and key stakeholders will be directly engaged in shaping the 
intervention. A Study Advisory Committee will be formed, comprising youth 
representatives, educators, school counsellors, and healthcare professionals, to 
ensure that diverse perspectives are represented throughout the study. The co-
production process will include three stages: (1) stakeholder engagement through 
discussion groups and needs assessment, (2) collaborative content review and 
cultural adaptation of the CMR materials, and (3) refinement of implementation 
procedures for Thai school settings. These activities will be guided by participatory 
models such as Hart’s Ladder of Children’s Participation (1992), with an emphasis on 
partnership and shared decision-making. This collaborative approach aims to ensure 
that the adapted CMR programme is contextually relevant, youth-centred, and feasible 
for delivery in Thai secondary schools. 
Phase 3: This phase will comprise a single-arm feasibility trial assessing the delivery 
of a culturally adapted Compassionate Mindful Resilience (CMR) programme within a 
Thai secondary school context. A total of 46 students aged 16–18 years from Grades 
10 to 12 at a large public secondary school will be recruited through a process of 
universal invitation followed by stratified random sampling. The intervention will consist 
of four weekly sessions delivered outside normal school hours to reduce disruption 
and mitigate the risk of stigma. Key feasibility outcomes will include recruitment and 
consent rates, session attendance, participant retention, and adherence. Acceptability 
will be explored through post-intervention focus group, with an emphasis on 
participants’ perceptions of the programme’s relevance, delivery format, and overall 
value. The findings will be used to assess the suitability of the intervention for broader 
implementation and to inform the design of a future controlled trial. 
This phase builds directly on the co-production work undertaken in Phase 2 and 
reflects a continued commitment to participatory and contextually grounded research 
practices. In addition, a sub-analysis will explore how students apply CMR strategies 
in their daily lives, including in challenging situations where they may be exposed to 
substance use within their peer or family environments. This will provide valuable 
insight into the real-world relevance and potential preventative value of the 
intervention. 
 

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Phase 2: Co-Production Phase with Online Interviews 
1. Introduction 
1.1 Background Information 
During this phase, the Evidence-Based Co-production methodology will be used to 
engage stakeholders in the adaptation of an intervention to the needs of young people. 
Focus groups, composed of health care professionals, youth representatives, and 
academics (e.g., teachers), will work together to adapt existing CMR protocols and 
develop a plan to improve the mental well-being outcomes in younger populations. 
The sessions will be 60-90 minutes long and will carefully look at how things will be 
delivered, how engagement might take place and any feasibility issues that may arise. 
These discussions will produce qualitative data, which will be analysed thematically 
with the help of NVivo. This means creating a youth co-produced strategy for CMR 
intervention that will for further feasibility testing. 
This stage utilises a structured, staged co-production framework that is informed by 
McConnell et al. (2021) and underpinned by Sherry Arnstein’s Ladder of Participation 
and Roger Hart’s Ladder of Children’s Participation. Engaging youth to inform and 
create their own solutions together, the research deliberately places youth 
participation at the “partnership” and “delegated power” levels, ensuring young people 
have a meaningful role in intervention design. 
 
2. Arnstein’s and Hart’s Models of Participation: A Review 
Sherry Arnstein’s Ladder of Participation (1969) encompasses eight rungs of citizen 
engagement. These rungs range from manipulation (non-participation) to citizen 
control (full empowerment). In this study, youth participation sits at the partnership and 
delegated power stages, demonstrating their involvement in decision-making 
processes. Roger Hart’s Ladder of Children’s Participation (1992) is an extension of 
Arnstein’s model for youth participation, which includes eight rungs ranging from 
tokenism to child-initiated, shared decisions with adults.  This study shows youth 
participation in the consulted but informed and the Adult-Initiated Shared Decisions 
with Youth, and Delegated Power categories of Hart. Thus, the youth have a share in 
decision-making and co-designing of intervention strategies. 
 
3. Methodology of Phase 2 
3.1 Step 1: Engagement is Building Trust and Understanding Needs 
Objective: Establish a relationship with key players and assess current attitudes, 
challenges and preferences about Compassionate Mindful Resilience (CMR) at Thai 
secondary school level. 
Methods: 
‐ We will conduct semi-structured interviews with students, teachers, school 
counsellors, and health care professionals to gain qualitative insights through 
online individual interviews (Archibald et al., 2019). 
‐ Online surveys will be used to collect quantitative data on the stress level and 
perceptions of mindfulness (Evans & Mathur, 2018). 

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‐ Through each of the workshops, the sub-committee would re-confirm 
stakeholder needs and co-design a solution (Gray et al., 2020). 
Participation Model Application: At this first stage, engagement is at Hart’s 
‘Consulted but Informed’ level. Although youth input is actively sought it is not 
tokenistic and is assured that the youth input is active. 
 
3.2 Step 2: Collaboration-Co-Creation of MBI Framework 
Objective: The second step is initiation of Co-creation of MBI Framework. The aim of 
this step is to move from consulting to co-design and to involve youth and stakeholders 
in co-creating key elements of the intervention. 
Methods: 
‐ Youth-led design panels will take place as small co-design groups with 
students, along with teachers and psychologists, who will be involved in refining 
the MBI content and the best formats for delivery. 
‐ Feedback loops: Continuous feedback, including review and pilot testing of 
elements of the MBI. 
‐ Workshops will be conducted in which a mutual understanding will be built so 
that the youth could take a decision on choosing the intervention features 
(Dodds & Hess, 2021). 
Participation Model Application: This activity corresponds to Hart’s “Adult-Initiated, 
Shared Decisions with Youth” level and Arnstein’s “Partnership” level and allows youth 
to meaningfully influence intervention design. 
 
3.3 Step 3: Evaluation-Youth as Co-Researchers 
Objective: Involving youth as co-researchers to evaluate the feasibility and 
effectiveness of the intervention. 
Methods: 
‐ Students who are ultimately included in the project will be trained professionally 
and given orientation in qualitative and quantitative data analysis, including 
NVivo. 
‐ Youth researchers would conduct focus group discussions to collect feedback 
from intervention participants on its applicability and effectiveness.  
‐ Workshops will organize youth, teachers, and researchers together for co-
interpreting the data or sense-making of data.  
‐ Youth will be encouraged to co-present study findings through academic 
presentations, blog posts, or written reports to promote dissemination of 
findings (Turba et al., 2022).  
‐ A Youth Advisory Board will potentially be created to keep youth involved during 
and after the study (Prior et al, 2022). 

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Participation Model Application: This last stage reflects a “Delegated Power” from 
Arnstein’s participation model (Arnstein, 1969) and involves an empowerment model 
whereby youth can be active agents in decision-making and knowledge dissemination. 
 
3.4 Framework of Phase 2: Co-Production Process 
Table 1: Framework of Phase 2 
Stage 
Objective 
Participants & 
Methods 
Participation 
Model 
Application 
Key Outcomes 
Step 1: 
Engagement – 
Understanding 
Needs and 
Building Trust 
Establish rapport 
with stakeholders 
and assess 
attitudes, 
challenges, and 
preferences 
regarding MBIs in 
Thai secondary 
schools. 
Small-Group 
Interviews (6-8 
participants 
per group): 
- Students 
(Aged 16-18) 
- Educators & 
School 
Counselors 
- 
Administrators 
& Policy 
Influencers 
Methods: 
- Online 
surveys 
- Focus group 
discussions 
- Virtual 
stakeholder 
workshops 
(Miro, breakout 
rooms) 
Hart’s 
'Consulted but 
Informed' level 
Identification of key 
barriers, 
facilitators, and 
preferences related 
to MBIs. 
Step 2: 
Collaboration – 
Co-Creation of 
the MBI 
Framework 
Transition from 
consultation to 
active co-design 
by engaging youth 
and stakeholders. 
Interactive Co-
Design 
Workshops: 
- Youth-Led 
Design Panels 
- Educator & 
Administrator 
Integration 
Workshops 
Methods: 
- Iterative 
feedback 
cycles 
- Co-Design 
Sprint 
Sessions 
- Consensus-
Building 
Workshops 
Hart’s 'Adult-
Initiated, Shared 
Decisions with 
Youth' level 
Development of an 
evidence-informed 
MBI framework. 

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Stage 
Objective 
Participants & 
Methods 
Participation 
Model 
Application 
Key Outcomes 
Step 3: 
Evaluation – 
Youth as Co-
Researchers 
Ensure that youth 
are actively 
involved in 
evaluating the 
feasibility and 
effectiveness of 
the intervention. 
Youth-Led 
Evaluation 
Teams: 
- Youth 
analyze data 
(NVivo) 
- Peer-Led 
Feedback 
Sessions 
- Collaborative 
Sense-Making 
Workshops 
- Knowledge 
Dissemination 
Arnstein’s 
'Delegated 
Power' level 
Active participation 
of youth in data 
interpretation and 
dissemination. 
 
4. Overall Expected Outcomes 
Strengthened relationships between learners, teachers and the school administrative 
team, in affiliation with the school. This partnership aims to enhance the power of youth 
in decision-making and to give students a greater say in interventions and school-
based policies around mindfulness and well-being. The intervention will be developed 
with the aim of meeting the needs of Thai secondary school students. This initiative 
allows students to analyse qualitative and quantitative data on NVivo and similar 
programmes to enhance their research skills.  
The long-term implementation of the CMR will be overseen by a Youth Advisory Board, 
ensuring the intervention remains sustainable. Additionally, they ensure knowledge 
sharing and policy influence by having youth disseminate their findings through 
presentations, blogs, academic reports, and policy briefs. This participatory approach 
will feed into wider education and mental health conversations, ensuring that youth 
engagement does not remain merely tokenistic and advances towards meaningful 
collaboration in the design and evaluation of the intervention. 
 
Phase 3: A Study Feasibility Testing of a Four-Week Compassionate Mindful 
Resilience (CMR) Intervention for Youth  
 
The research study involves a Four-Week Compassionate Mindful Resilience (CMR) 
Intervention for young people. We will conduct a single-arm feasibility study to 
evaluate the feasibility, acceptability, and preliminary effectiveness of a Four-Week 
Compassionate Mindful Resilience (CMR) Intervention for secondary school students 
in Thailand. 
   
1. Introduction 
1.1 Background Information 
Adolescence is a critical period marked by significant emotional, cognitive, and social 
changes, making it a vulnerable time for the development of anxiety and emotional 
dysregulation. Schools play a pivotal role in supporting students' mental health, and 
mindfulness-based interventions (MBIs) have emerged as a promising approach to 
address these challenges. Mindfulness-Based Interventions (MBIs) have gained 
widespread recognition as effective therapeutic approaches for managing mental 

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health disorders, including anxiety, depression, and substance use behaviours (Kabat-
Zinn, 2003). MBIs are based on the Buddhist contemplative tradition but have been 
adapted for clinical and educational use to promote well-being through focused 
attention, awareness without judgment, and self-regulation (Baer 2003; Bishop et al., 
2004). Studies have shown that MBIs are particularly useful for the youth who 
experience heightened emotional reactivity, peer pressure, and risk-taking behaviour 
and substance use (Hwang et al., 2018). Mindfulness training has been shown to 
significantly enhance cognitive resilience, emotional regulation, and stress 
management—three protective factors against substance use, as supported by 
numerous studies (Zoogman et al., 2015; Tang, Hölzel, & Posner, 2015). The 
Compassionate Mindful Resilience (CMR) Programme integrates mindfulness and 
compassion-based approaches to improve emotional well-being and resilience of 
individuals facing mental health challenges. Wilson et al. (2023) have demonstrated 
that a Four-Week Compassionate Mindful Resilience (CMR) programme resulted in 
significant improvements in participants’ levels of mindfulness, mental well-being, self-
compassion, and resilience, alongside reductions in anxiety and depressive 
symptoms. However, these findings were drawn from studies involving adult general 
population samples. To date, the CMR programme has not been formally tested with 
adolescent populations or individuals with substance use difficulties. This study seeks 
to address this gap by evaluating the feasibility and acceptability of delivering the CMR 
programme in Thai secondary schools among adolescents. 
While mindfulness is deeply embedded within Thai Buddhist cultural traditions, the 
structured implementation of mindfulness-based interventions (MBIs) in educational 
settings remains relatively limited. In recent years, several school-based mindfulness 
programmes have been piloted in Thailand with encouraging outcomes. For instance, 
MBIs have been associated with enhanced academic performance among secondary 
school students (Lwin et al., 2025), improved emotional regulation and reduced 
depressive symptoms in primary school children (Siripattarawit et al., 2019), and 
improved executive function and behavioural self-regulation among preschoolers at 
risk (Lertladaluck et al., 2021). In adolescents, traditional mindfulness practices have 
also been linked to reduced stress and improved emotional control (Jarukasemthawee 
et al., 2020). 
Despite these promising findings, existing studies tend to be limited in scope, duration, 
and methodological robustness. There remains a critical lack of feasibility studies 
assessing structured, culturally adapted MBIs tailored specifically for adolescents. The 
present study aims to contribute to this gap by adapting and evaluating the CMR 
programme within the Thai secondary school context, guided by evidence from 
previous research and frameworks for youth engagement. 
 
1.2 Study Rationale  
Mental health challenges among adolescents in Thailand have become a significant 
public health concern, with national surveys indicating rising rates of stress, anxiety, 
depressive symptoms, and self-harm behaviours (World Health Organization, 2025; 
Ministry of Public Health et al., 2022). Such difficulties often emerge during 
adolescence—a period marked by developmental vulnerabilities and increasing peer 
pressure—which is consistently linked with elevated risk of substance use 
(Esmaeelzadeh et al., 2018; Centers for Disease Control and Prevention, 2022). 
These associations are mediated by factors such as low emotional regulation, poor 
coping strategies, and diminished psychological resilience (Keyes & Platt, 2024). 
 

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Substance use among Thai youth has also been identified as a pressing issue. Early 
initiation of alcohol and drug use is associated not only with academic 
underachievement and disrupted family relationships but also with longer-term risks 
of dependency and chronic mental illness (Ministry of Public Health et al., 2022; 
World Health Organization, 2021). Despite ongoing prevention campaigns, current 
strategies largely emphasize risk education and deterrence, with limited focus on 
strengthening protective psychosocial factors like resilience, compassion, and 
mindfulness. 
Compassionate Mindful Resilience (CMR) interventions—combining mindfulness, 
self-compassion, and resilience training—have shown promise internationally. For 
instance, school-based mindfulness programmes have improved adolescent well-
being, reduced depressive symptoms and stress, and boosted emotional regulation 
(Kuyken et al., 2013). Similarly, compassion-based programmes such as the Mindful 
Self-Compassion for Teens (MSC-T) have demonstrated feasibility and protective 
effects on mental health in at-risk youth (Bluth et al., 2024). Notably, socio-emotional 
skills-focused interventions, such as mindfulness and compassion, are recognised 
by the World Health Organization as effective strategies to build resilience and offer 
healthy alternatives to risk behaviours, including substance use (World Health 
Organization, 2021). 
Despite this growing evidence, there remains a gap: no feasibility studies of CMR 
have been conducted within Thai school settings, where cultural factors—collectivist 
values, Buddhist mindfulness traditions, and stigma around mental health—may 
influence both implementation and impact. To address this critical gap, our feasibility 
study will evaluate the acceptability, engagement, and potential psychosocial 
outcomes of CMR among Thai adolescents, laying the groundwork for larger-scale 
trials and informing culturally adapted mental health interventions in educational 
settings. 
 
Aims and Objectives 
The primary aim of this feasibility study is to evaluate the implementation, 
acceptability, and preliminary effectiveness of a Four-Week Compassionate Mindful 
Resilience (CMR) intervention for Thai secondary school students, with a focus on 
stress management, emotional regulation, overall well-being, and prevention of 
substance use. Feasibility parameters include recruitment, retention, adherence, and 
acceptability to determine readiness for a future large-scale trial. 
Quantitative outcomes will focus on mindfulness, self-compassion, resilience, well-
being, and substance-use indicators; perceived changes in stress management and 
emotion regulation will be explored qualitatively via post-intervention focus groups 
and brief exit interviews. 
Research Questions 
The study will be guided by the following key research questions: 
1. Is it feasible to deliver the Four-Week Compassionate Mindful Resilience 
(CMR) intervention to Thai secondary school students in terms of recruitment, 
retention, adherence, and acceptability? 
2. What are the preliminary indications of effectiveness on well-being and substance-
use indicators (quantitative), and how do students describe shifts in emotional 
regulation skills (qualitative)? 
 
 

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Table 2: Research Questions – Aims – Outcomes/Measures Mapping 
Research Question 
Corresponding Aim 
Outcomes / Measures 
1. Is it feasible to deliver the Four-
Week Compassionate Mindful 
Resilience (CMR) intervention to 
Thai secondary school students in 
terms of recruitment, retention, 
adherence, and acceptability? 
To evaluate feasibility of 
the CMR intervention. 
Recruitment log, 
attendance/retention records, 
adherence monitoring, 
acceptability questionnaire, focus 
group feedback. 
2. What are the preliminary 
indications of effectiveness on 
overall well-being and 
psychosocial skills (mindfulness, 
self-compassion, resilience) and 
on substance-use indicators 
(quantitative), and how do 
students describe changes in 
stress management and emotion 
regulation (qualitative)? 
To explore preliminary 
outcomes related to 
stress management, 
emotional regulation, 
overall well-being, and 
prevention of substance 
use. 
Psychosocial questionnaires 
(mindfulness, self-compassion, 
resilience, WHO-5); self-reported 
substance-use indicator items; 
qualitative themes from focus-
group/exit interviews on stress 
management and emotion 
regulation. 
 
 
3. Study Design 
This feasibility study follows a single-arm pre–post design to evaluate quantitative changes 
in mindfulness, self-compassion, resilience, overall well-being, and self-reported substance-
use indicators. Perceived shifts in stress management and emotion regulation will be 
explored qualitatively via focus groups. A control arm was not included, as the primary aim 
is to evaluate feasibility, acceptability, and engagement, rather than efficacy, and a 
single-arm design is also more practical and cost effective at this stage. While this limits 
assessment of randomization acceptability for a future randomised controlled trial 
(RCT), qualitative feedback will explore participants' willingness to be randomised. 
Findings will inform the design of a full-scale RCT, where a control arm will be 
incorporated to rigorously evaluate effectiveness.   
The study will be conducted at Mukdahan Wittayanukul School, a large public 
secondary school in Mukdahan Province, located in the northeastern region of Thailand. 
The school offers education from Mathayom 1 to 6 (Grades 7–12) and serves 
approximately 2,700 students. Average class sizes range from 35 to 45 students. This 
setting represents a typical large urban secondary school, providing a relevant and 
logistically feasible context for the delivery and assessment of the adapted CMR 
intervention. 
An overview of the study’s procedural elements is provided below, covering facilitator 
arrangements, withdrawal and participant support, data management, translation and 
transcription, and cultural and contextual adaptation. 
 
A. Facilitator and Delivery: The CMR sessions will be delivered by the PhD 
candidate, who has completed training in the Compassionate Mindful Resilience 
(CMR) programme with MindfulnessUK under the guidance of an accredited 
CMR trainer. The PhD candidate will deliver the programme under academic 
supervision from Queen’s University Belfast and with local support from 
designated school staff.  
§ 
 Delivery schedule. Four weekly group sessions, 90 minutes each, 
delivered on school premises in a quiet designated room after classes, 

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provisionally between 16:00–17:30 (final start time to be agreed with 
the school timetable). Total participants contact time: ~6 hours over four 
weeks. 
§ 
Safeguarding. A school counsellor will be on call and will intervene only 
in exceptional safeguarding circumstances that meet the school’s 
predefined thresholds (e.g., imminent risk of harm or child-protection 
concerns). The counsellor will not attend routine sessions or access 
research data; any involvement will follow school safeguarding policy and 
be recorded within school systems, separate from research data. 
B. Withdrawal and Support Procedures: Participants may withdraw at any point 
without giving a reason. 
§ 
 Data deletion. Participants may request deletion of all their data 
(including coded/pseudonymised data) up to 7 days after the end of all 
data-collection activities. After this date, removal may not be feasible 
because data will have been de-identified and/or aggregated for analysis. 
(Pseudonymisation = replacing direct identifiers with a study code stored 
separately under restricted access.) 
§ 
Distress pathway. If a participant becomes distressed, the facilitator will 
pause or stop the activity according to participant preference. 
Participants may skip any question, take a break, or leave the study 
altogether without penalty. Where observed indicators meet the school’s 
safeguarding threshold, the facilitator will escalate to the on-call school 
counsellor, who will intervene only in exceptional safeguarding 
circumstances (e.g., imminent risk of harm or child-protection concerns). 
The counsellor will not attend routine sessions or access research data; 
any involvement will follow school policy and be recorded within school 
safeguarding systems, separate from research data. All escalations will 
be logged; the CI will be notified within 24 hours, and serious adverse 
events will be reported per governance requirements. 
C. Data Management and Transfer: Data will be collected and stored securely in 
Thailand, pseudonymised at source, and managed in compliance with data 
protection legislation and Queen’s University Belfast (QUB) governance. 
Pseudonymised data may be securely transferred from Thailand to QUB for 
analysis; identifiable information will remain in Thailand and will not be 
transferred. For focus groups, audio recordings will be stored in encrypted form 
in Thailand, transcribed verbatim and accuracy-checked, after which the raw 
audio will be permanently deleted; only pseudonymised transcripts (not raw 
audio) will be transferred. Paper questionnaires will be scanned and verified; 
originals will then be destroyed in Thailand (consent originals retained as 
required by governance). Encryption, role-based access controls, and least-
privilege permissions will be applied end-to-end. Explicit consent for any cross-
border transfer will be obtained via the consent forms. 
D. Translation and Transcription: For qualitative interviews and focus groups, 
audio recordings in Thai will be transcribed verbatim and translated into English 
by the PhD candidate, with support from a bilingual Thai academic collaborator. 
A proportion of transcripts will be cross-checked to ensure accuracy and fidelity. 
E. Cultural and Contextual Adaptation: In addition to these procedures, feasibility 
outcomes will capture reflections on cultural, religious, and contextual adaptation 

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of the CMR intervention. This will ensure that findings directly inform the 
appropriateness, acceptability, and scalability of the programme in Thai school 
settings. 
3.1 Population 
The target population comprises students in Grades 10 to 12 (Mathayom 4–6) at 
Mukdahan Wittayanukul School, a large public secondary school in northeastern 
Thailand. According to school records dated 15 November 2023, there were 533 
students enrolled in these grades (203 in Grade 10, 152 in Grade 11, and 178 in Grade 
12). Eligible participants are aged 16–18 years and will be required to provide written 
consent, alongside informed consent from a parent or legal guardian in accordance with 
Thai research ethics. All students in the target grades will be invited to express interest, 
and approximately 46 participants will be selected through stratified random sampling 
based on age-related representativeness to ensure balanced representation across 
grade levels and to reduce selection bias. 
 
3.2 Sample Size 
This feasibility study will use the Confidence Interval (CI) approach to determine the 
sample size (Lancaster et al., 2004; Thabane et al., 2010). To estimate feasibility 
parameters with 95% confidence and a ±15% margin of error, 33 participants are 
needed. Allowing for a 20% dropout rate and additional caution due to potential 
stigma-related challenges, the study will recruit 46 participants (Viechtbauer et al., 
2015). While this feasibility study is based on individual-level estimates, we recognise 
that a future effectiveness trial would benefit from a cluster randomised design to 
prevent contamination. In such a trial, entire schools or classrooms would be allocated 
to intervention or control arms to maintain group independence and minimise bias. 
 
4. Intervention 
The Compassionate Mindful Resilience (CMR) programme (MindfulnessUK) is a four-
week, structured, group-based intervention designed to strengthen mindfulness, self-
compassion, emotion regulation, and resilience. The programme integrates guided 
practices and reflective exercises to support stress reduction and resilience building, 
while promoting substance-use prevention and overall well-being. Each session 
includes prescribed breathing practices, awareness meditation, cognitive defusion 
techniques, and discussion of mindfulness-based choice (Kabat-Zinn, 2003). The 
programme aims to help students cope with stress, increase self-awareness, and build 
resilience (Goldberg et al., 2021). Student input gathered through facilitated discussions 
will inform subsequent co-production activities to refine delivery details and ensure 
alignment with secondary-school needs. 
 
4.1 Weekly Session Plan for the Four-Week CMR Programme 
This Four-Week CMR programme aims to teach students stress reduction and 
emotional regulation techniques (Kabat-Zinn, 2003) while supporting mental well-
being through structured group sessions that foster peer support. Four weekly group 
sessions (90 minutes each) will be delivered on school premises in a quiet designated 
room after classes, provisionally between 16:00–17:30 (final start time to be agreed 
with the school timetable). The researcher will accommodate 46 participants, divided 
into two groups led by the researcher (TS – PhD candidate), who has completed CMR 
training and is currently undertaking the Train to Teach CMR course with 
MindfulnessUK. If a student misses a session, they will receive recap materials and 

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individual guidance through school channels (e.g., teacher liaison or printed handouts) 
to maintain engagement once the missed session has been completed.  Fidelity 
monitoring will involve session logs, adherence checklists, and student feedback to 
ensure consistent delivery and alignment with programme goals. A school counsellor 
will be on call for all sessions to support safeguarding. 
 
Table 3: Intervention details 
Week  
Module 
Overall Details 
Home practices 
Week 1 Module 1 -Exploring Mindfulness and Awareness, 
where participants are introduced to the 
fundamentals of mindfulness and its role in 
stress reduction and emotional regulation 
(Kabat-Zinn, 2003).  
-They will learn to distinguish between 
"doing mode" and "being mode," fostering 
greater self-awareness (Brown & Ryan, 
2003).  
Home practices for 
this week involve 10-
minute daily 
breathing exercises, 
journaling stressors, 
and using body scan 
meditations before 
sleep to deepen self-
awareness and self-
compassion 
Module 2 -Understanding Compassion, participants 
explore the concept of self-compassion and 
its impact on emotional resilience (Neff, 
2015). 
Week 2 Module 3 - Building Emotional Intelligence, 
participants develop skills in recognizing 
and managing emotions. 
-Introducing Emotional Intelligence explores 
the importance of emotional intelligence (EI) 
in well-being and stress management 
(Goleman, 1995).  
-Participants learn the RAIN (Recognise, 
Acknowledge, Investigate, Nurture) and 
HEARTS models, which help them navigate 
emotions effectively and enhance self-
awareness. 
Key mindfulness 
practices this week 
include emotional 
awareness exercises, 
mindful listening 
techniques, and 
journaling about 
emotional triggers to 
improve emotional 
regulation and 
interpersonal 
communication. 
 
Module 4 -Cultivating Emotional Intelligence, where 
participants strengthen mindful 
communication and active listening skills 
(Siegel, 2010).  
-They learn to differentiate between reacting 
impulsively and responding mindfully by 
practicing the STOP method (Stop, Take a 
breath, Observe, Proceed mindfully) to 
manage emotional triggers. 
Week 3 Module 5 -Strengthening Resilience shifts the focus 
toward emotional stability and coping 
strategies. 
-Developing Resilience, participants explore 
how mindfulness and self-compassion 
contribute to resilience (Lazarus & Folkman, 
1984).  
-They learn to recognise personal stress 
triggers and regulate emotions through 
affectionate breathing and self-soothing 
techniques (Cohen et al., 1983).  
Home practices this 
week involve naming 
emotions, cognitive 
reappraisal exercises, 
and engaging in 
mindful movement to 
enhance 
psychological 
resilience. 
 

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Week  
Module 
Overall Details 
Home practices 
-This module highlights the role of 
relationships in resilience-building, 
emphasizing the importance of social 
connection. 
Module 6 -Enhancing Resilience introduces 
personalised meditation phrases as a tool 
for emotional grounding (Meichenbaum, 
2007).  
-Participants deepen self-awareness and 
self-care strategies, integrating mindful 
movement practices to support stress 
regulation. 
Week 4 Module 7 -Connected, focuses on sustaining 
mindfulness, compassion, and resilience in 
daily life. 
-Feeling Resourced, participants cultivate 
gratitude and self-appreciation, reinforcing 
emotional stability (Fredrickson, 2001).  
-They explore deep breathing techniques to 
manage stress and learn strategies for 
overcoming negativity bias through 
Mountain Meditation and gratitude 
journaling. 
 
Module 8 -Feeling Connected encourages participants 
to integrate their learnings by developing a 
personalised mindfulness and resilience 
plan (Creswell, 2017).  
-They are introduced to urge surfing 
techniques for managing impulsive 
behaviours, mindful decision-making, and 
social awareness practices such as mindful 
listening (Brown & Ryan, 2003). 
- Final activities include guided urge surfing 
meditations, mindful eating exercises, and 
reflective journaling to ensure long-term 
mindfulness integration. 
 
At the conclusion of the CMR Programme, participants reflect on their progress and 
create a personal mindfulness plan to sustain their practice. By integrating 
mindfulness, self-compassion, emotional resilience, and positive psychology 
strategies, the programme equips individuals with practical skills to navigate stress, 
regulate emotions, and cultivate self-awareness in their everyday lives. 
 
5. Participants and Selection 
Participant recruitment will be conducted through secondary schools in Thailand. The 
target participants are students in Grades 10 to 12 (Mathayom 4–6) at a Thai 
secondary school. The selection process has been designed to avoid stigma and 
selection bias by not limiting participation. Instead, the study will be framed as a 
general mental well-being initiative open to all students within the eligible age group. 
The selection process will proceed as follows: 
1. Universal Invitation: 
All students in the eligible grades will be invited to attend an information 

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session led by the PhD candidate. This session will provide an overview of the 
study's purpose, procedures, participants' rights, and the informed consent 
process. 
2. Expression of Interest: 
Students who express interest will receive a Participant Information Sheet and 
consent/assent forms at the information session or via teacher distribution. 
Students under 18 will be encouraged to discuss participation with a parent or 
legal guardian; if they wish to proceed, the student/parent will return the 
signed forms to the teacher within one week. Teachers act only as 
administrative liaisons, facilitating the distribution and collation of invitation 
materials; they will not have access to research data or to the final list of 
enrolled participants. The researcher will then meet students at school to 
answer questions and confirm consent/assent via school channels; no 
personal contact details will be collected or retained. Participation is voluntary 
and non-coercive. 
3. Stratified Random Selection: 
From the pool of students who return completed consent forms, approximately 
46 participants will be randomly selected. Stratification will be applied to 
ensure balanced representation across each grade level, including 16 
students from Grade 10, 15 from Grade 11, and 15 from Grade 12. This 
approach supports developmental diversity and age-related 
representativeness. 
4. Notification of Selection: 
Students selected to participate will be informed individually and invited to 
attend the first session of the intervention. 
Teachers will only distribute and collate expressions of interest and consent forms. 
They will not administer or collect questionnaires, observe completion, or access the 
enrolment list. All questionnaires will be administered and collected by the researcher 
in a designated room without teachers present. Participation records and responses 
remain confidential and accessible only to the research team. 
 
Enrolled participants will take part in four weekly 90-minute group sessions on school 
premises after classes (provisionally 16:00–17:30); total contact time ≈ 6 hours over 
four weeks. The CMR programme develops mindfulness, self-compassion, and 
emotion-regulation skills to support student well-being and academic engagement. 
 
5.1 Screening Recruitment, and Withdrawal Procedures 
5.1.1 Screening Recruitment 
The recruitment plan was developed in consultation with key stakeholders from a Thai 
secondary school, including school counsellors, teachers, student welfare officers, 
and health professionals. The selected research site is Mukdahan Wittayanukul 
School, a large public secondary school located in Mukdahan province, in the 
northeastern border region of Thailand. The school enrols approximately 2,700 
students across Mathayom 1–6 (Grades 7–12), with average class sizes ranging from 
35 to 45 students. It operates under the Ministry of Education and is recognised as 
one of the leading schools in the province.  
Eligible students will be invited to an information session outlining the study’s aims, 
procedures, participants’ rights, and the consent process. This session will be 
delivered by the PhD candidate researcher. Interested students will receive a 
Participant Information Sheet and consent forms to review with their parent or legal 

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guardian. Students under 18 must return signed forms within one week to confirm 
eligibility. Participation is entirely voluntary; only students who provide both informed 
consent and parental consent will be enrolled. Those who do not consent will not take 
part in any sessions or data collection (see Figure 1). 
 
 
 
 

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Figure 1: Participant Recruitment Process 

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The intervention will be offered as an opt-in programme, and only students who 
provide informed consent and parental consent will be enrolled. Students who do not 
consent will not be required to participate in the sessions or any data collection 
activities. 
Teachers will support recruitment by distributing invitation materials and collecting the 
names of students who express interest. Families will be informed through the 
provided documents and encouraged to discuss participation together. Once students 
express their interest, teachers will notify the researcher, who will then meet the 
students at the school, answer questions, and collect consent. From the pool of eligible 
students, 46 participants will be selected using stratified random sampling to ensure 
balanced representation across Grades 10 to 12. 
To minimise disruption to classroom learning, all mindfulness sessions will be 
scheduled after school hours. While this arrangement may result in some visibility of 
student participation, efforts will be made to protect privacy and prevent unnecessary 
attention. Non-participating students will continue with their usual school routine or 
remain in supervised areas. The session schedule will be clearly outlined in the 
Participant Information Sheet to support informed decision-making. This approach 
was co-produced with school counsellors and teachers to promote integration into the 
school timetable while being mindful of potential concerns around student visibility. 
 
5.1.2 Withdrawal Procedures 
 
Attendance will be recorded for feasibility reporting only and does not constitute a 
withdrawal criterion. Participation is voluntary; students may withdraw at any time 
without giving a reason or facing consequences, by notifying the researcher directly 
or via a teacher/counsellor who will relay the message to the research team. On 
withdrawal, no further data will be collected. Participants may request deletion of all 
their data (including coded/pseudonymised data) up to 7 days after the end of all data-
collection activities. After this date, deletion will not be feasible because the dataset 
will have been de-identified and/or aggregated for analysis. Focus groups only: 
withdrawal is permitted until the group begins; once underway, individual contributions 
cannot be isolated from the recording. The school counsellor is on call and will 
intervene only in exceptional safeguarding circumstances in line with school policy, 
and any such involvement will be recorded within school safeguarding systems, 
separate from research data. 
 
To provide a non-stigmatising and supportive withdrawal process, the procedure will 
be overseen by the designated school counsellors and the research team. If a 
participant chooses to withdraw, this information will not be disclosed to teachers 
unless there is a specific concern related to the student’s well-being that warrants their 
involvement. In such cases, disclosure will be limited and handled in a manner that 
prioritises the participant’s privacy and emotional safety. This approach aligns with the 
study’s safeguarding protocol to ensure participants’ rights and well-being are upheld 
throughout. 
 
The school counsellor, teacher, and welfare officer will be informed about the 
intervention and made available to provide support if needed. If a student shows signs 
of ongoing or severe distress, the school counsellor will be notified to assess the 
situation and, using their professional judgement, determine whether a referral to 

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external mental health services is appropriate. A distress protocol will guide the 
response to ensure the student’s well-being and inform appropriate next steps. 
 
To ensure clarity and uphold ethical standards, three distinct procedures have been 
outlined to address different withdrawal scenarios: (a) attendance and analytic 
handling, (b) voluntary withdrawal, and (c) withdrawal or session discontinuation due 
to emotional distress. Each scenario is managed with appropriate support 
mechanisms to protect the participant’s rights, safety, and emotional well-being. 
 
(a) Attendance and Analytic Handling 
Participants are encouraged to attend all four sessions, as consistent attendance 
supports meaningful engagement with the programme. Attendance will be recorded 
and analysed as part of feasibility outcomes (recruitment, retention, adherence, 
acceptability). Missing sessions will not trigger withdrawal; participants who miss 
sessions will remain in the study and will still be invited to complete all follow-up 
assessments. For exploratory analyses of programme effectiveness, only those who 
attend at least three sessions will be included, as fewer sessions are unlikely to provide 
sufficient exposure to the intervention. Support will continue to be offered to all 
participants, and those experiencing difficulties will be referred to the school counsellor 
if needed. 
 
(b) Voluntary Withdrawal 
Participants may withdraw at any time without giving a reason; this will not affect their 
relationship with the school or access to support. Upon withdrawal, identifiable data 
are deleted immediately. 
• 
Questionnaires/sessions (non-FG): if a participant requests complete 
deletion (including pseudonymised data), this may be done up to 7 days after 
the end of all data-collection activities; after this period, removal may not be 
possible because data will have been de-identified and aggregated for analysis. 
• 
Focus groups: participants may withdraw until the group begins; once a focus 
group has started, removal of an individual’s data is not feasible due to multi-
party recording and the need to protect other participants’ confidentiality. 
These rights are explained during consent/assent and are reiterated during the 
study. 
 
(c) Procedures for Managing Emotional Distress 
While it is anticipated that participants may experience emotions such as sadness or 
contemplation during the programme, a safe and supportive environment will be 
maintained throughout. Participants have the right to withdraw from the study at any 
time and for any reason, without consequences for their academic performance or 
relationships with school staff. In some cases, participants may also be advised to 
withdraw for their own well-being. 
If a student displays signs of moderate to severe emotional stress, such as persistent 
tearfulness, anger, or notable changes in behaviour, they will be invited to pause their 
participation and referred to the school counsellor to discuss their continued 
involvement in the study. 
In situations where a participant becomes distressed during a session, the session 
may be paused, interrupted, or discontinued—either at the participant’s request or at 
the discretion of the facilitator. The facilitator will assess the situation based on the 
student’s emotional state and document the incident appropriately. 

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If a session is discontinued due to distress, a follow-up check will be conducted within 
24–48 hours to monitor the participant’s well-being. If distress persists or is considered 
severe, the case will be referred to the school counsellor for further evaluation and 
support, including external referral where appropriate, in line with the Distress 
Protocol. 
Where a participant exhibits significantly disruptive behaviour or indicates that 
continued participation may not be appropriate, the researcher will consult with the 
school counsellor, principal, and research team. Together, they will determine whether 
withdrawal from the programme is in the student’s best interest, prioritising safety, 
dignity, and access to support. 
In cases of repeated or escalating distress across multiple sessions, the research 
team will reassess the student’s suitability to continue in the programme. This decision 
will be made collaboratively by the principal investigator, facilitation team, and school 
counsellor, with a focus on safeguarding the student’s well-being. If continued 
participation is judged inadvisable, the student will be supported to withdraw and 
referred to appropriate external or school-based services. 
 
5.2 Recruitment and Participant Safeguarding (Identification, Invitation, 
Consent) 
5.2.1.1 Identification of Participants 
All participants’ information will be treated with strict confidentiality; their identities will 
be protected, and no identifiable information will be contained within the research data. 
The school counsellor, teacher, and welfare officer will be formally informed about the 
intervention and provided with a summary of its content and objectives. Their 
awareness and preparedness are essential, as they may be required to offer emotional 
support or initiate safeguarding referrals should any students experience distress or 
disclose sensitive information during or following participation in the programme. 
- Adolescents between 16 and 18 years of age.  
In Thailand, adolescents aged 16–18 are still considered minors under national 
research ethics guidelines. Therefore, we will obtain both written consent from 
the student and informed consent from a parent or legal guardian before 
participation. This dual consent process is particularly important given the 
sensitive nature of the topic and the school-based setting. 
- Willing to engage in a mindfulness-based intervention programme. 
- Ability to understand and communicate in Thai.  
- Ability to consent to taking part in the study. 
Students will be excluded if they have significant mental health conditions (e.g., 
schizophrenia, bipolar I disorder, or severe major depression with psychotic features) 
that may impede participation, cognitive impairments that prevent comprehension of 
the mindfulness intervention, or if they are concurrently involved in another 
psychological intervention that might confound study results. Furthermore, students 
who wish to participate may indicate their interest by contacting a designated school 
representative, ensuring that all self-referrals are managed through these trusted 
gatekeepers rather than directly by the researcher. The Thai secondary school will 
assist in identifying adolescents who meet the selection criteria. Through this careful 
selection and transparent process, we aim to contribute valuable insights to future 
studies and interventions, improving mental health outcomes within the community.  
 
 
 

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5.2.1.2 Culturally Sensitive Approach to Invitation 
In alignment with the study’s focus on promoting mental health and emotional 
resilience among adolescents, all invitation and consent materials will be designed to 
ensure cultural relevance and developmental appropriateness. The intervention will 
be introduced as a school-based, opt-in programme aimed at supporting students’ 
well-being through mindfulness, emotional regulation, and self-compassion. All 
materials will be carefully worded to avoid language that may be perceived as 
diagnostic, clinical, or stigmatising. 
The invitation process will prioritise inclusivity, psychological safety, and student 
autonomy. All students in Grades 10 to 12 will be invited to attend an information 
session outlining the aims and procedures of the study, along with their rights as 
potential participants. Students who express interest will be encouraged to discuss 
participation with their parents or legal guardians. The researcher will not access any 
personal or behavioural records and will only engage with students. Rather, who 
voluntarily express interest. All invitation and consent materials will be carefully 
worded using neutral, developmentally appropriate, and non-stigmatising language. 
This approach aims to protect students’ dignity, promote psychological safety, and 
support informed, voluntary participation. Students who return completed consent and 
parental consent forms will be considered eligible for enrolment. 
This culturally sensitive approach aims to uphold participant dignity, minimise the risk 
of stigma, and ensure that all participation is fully informed and freely chosen. By 
framing the CMR programme as a general well-being initiative, the study seeks to 
foster engagement across a diverse student population in an inclusive and non-
discriminatory manner. 
 
6. Feasibility Metrics, Data Collection, Outcome Measures and Follow-Up 
Assessment 
6.1 Measures and Data Collection Procedures 
6.1.1.1 Quantitative Data Collection & Feasibility Metrics 
Feasibility metrics include recruitment, consent, attendance, retention, adherence, 
and acceptability (Goldberg et al., 2021). To ensure culturally and contextually 
appropriate measurement, this study will employ validated Thai-language scales. The 
selected outcome measures include: 
 
-Srithanya Sati Scale (11 items): A Thai Mindfulness Questionnaire developed 
by Dr. Orawan and Dr. Chatchawan Silpakit, reflecting mindfulness practices relevant 
to Thai culture (Silpakit and Silpakit, 2014). 
 
-Self-Compassion Scale for Youth-Thai version (17 items): Adapted from Neff 
et al. (2021) and translated by Kongsonthana (2022), this scale assesses how young 
individuals treat themselves with kindness in times of difficulty. 
 
- The Connor-Davidson Resilience Scale (10-Item CD-RISC) was originally 
developed by Connor, K.M. and Davidson, J.R.T. (2003) and translated by 
Vongsirimas N. (2017). This scale is widely used to assess resilience in the youth 
population. 
 
- WHO-5 Well-being Index – Thai version (5 items): A brief, positively worded 
scale assessing subjective psychological well-being over the past two weeks (WHO, 
2024). Each item is rated on a 6-point Likert scale, with higher scores indicating greater 
well-being. The Thai version was officially translated and released by the World Health 
Organisation and is publicly available for academic, non-commercial use. Its brevity 
and developmental appropriateness make it suitable for school-based research 
involving adolescents and sensitive topics such as emotional well-being (WHO, 2024). 

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Additionally, feedback on the CMR intervention will be collected from all participants 
through post-intervention questionnaires to gain a more in-depth understanding of 
their experiences and to complement the qualitative analysis. 
 
6.1.1.2 Qualitative Data Collection & Analysis 
 
A focus group with up to eight students will be conducted using purposive sampling to 
ensure variation by (i) grade (10–12), (ii) gender, (iii) level of engagement with CMR 
(e.g., completers and partial attenders), and (iv) self-reported acceptability/perceived 
usefulness of the sessions. 
 
Recruitment and consent. Recruitment will occur in the final programme week 
following an information session. Students who express interest will be considered for 
invitation against the sampling frame above; assent/consent will be obtained from the 
student and a parent/guardian using approved forms. Participation is voluntary and 
confidentiality will be maintained. 
 
Selection notice. If expressions of interest exceed available places, invitations will be 
issued purposively to achieve the sampling balance; within each stratum, selection 
may be random. Consequently, some volunteers may not be selected. Non-selection 
has no impact on participation in the programme or access to support. 
 
Exit interviews. To understand barriers to engagement, students with lower attendance 
(fewer than three of four sessions) may be invited to a brief exit interview under the 
same consent procedures. 
 
Sessions will be moderated by the PhD researcher. A school counsellor will be on call 
during all sessions for safeguarding support and escalation. Discussions and 
interviews will be audio-recorded, transcribed verbatim in Thai, and translated into 
English by the researcher with support from a bilingual collaborator;10% of transcripts 
will be spot-checked for fidelity. All qualitative materials will be pseudonymised prior 
to analysis. The bilingual collaborator will sign a contract to keep the confidentiality 
and identity of the participants. 
 
The Focus Group Guide (see Appendix 1) is structured around five key areas: (1) 
overall experience with the CMR sessions, (2) perceived impact on mental health 
and well-being, (3) changes in stress and emotional regulation, (4) application of 
CMR skills in everyday life, including coping with situations involving substance use 
by peers or family members, and (5) suggestions for programme improvement. 
The guide is informed by qualitative research best practices (Krueger & Casey, 
2015) and piloted tools (Guest, Bunce, & Johnson, 2006). Questions are phrased in 
a developmentally appropriate and non-stigmatising manner. 
 
The focus group will be audio-recorded, transcribed verbatim in Thai, translated into 
English, and analysed thematically using Braun and Clarke’s (2006) six-step approach 
(reflexive thematic analysis). Coding will be carried out by the researcher and reviewed 
by a second coder to ensure credibility. Confidentiality will be maintained; all materials 
will be pseudonymised, and quotations will be de-identified. Ten percent of transcripts 

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will be spot-checked for fidelity, and NVivo will be used for data management with a 
maintained audit trail. 
 
6.2 Outcome Measures and Follow-Up Assessment 
This study will assess feasibility and mental well-being outcomes using quantitative 
and qualitative methods. Feasibility will be evaluated through recruitment, retention, 
session attendance, and participant engagement, analysed using descriptive statistics 
and session logs (Goldberg et al., 2021). 
A remote follow-up assessment at three months post-intervention will evaluate the 
long-term impact on mental well-being outcomes, and engagement with mindfulness 
practices. The final timeframe will be determined during the co-production phase to 
ensure feasibility. The findings will inform the development of future large-scale trials 
and potential adaptations of interventions. Follow-up will be coordinated via school 
channels using pseudonymised study codes; no personal contact details will be 
collected or retained. 
 
7. Data storage 
All paper-based data, including questionnaires and other study documents, will be 
securely scanned in Thailand, pseudonymised at source, and saved in electronic 
form on secure Queen’s University Belfast (QUB) systems (e.g., 
OneDrive/SharePoint) with password-protected, role-based access restricted to the 
research team. All handling will comply with applicable data-protection legislation, 
and QUB Research Governance and Integrity policies. Following verification of the 
scans, the original paper documents will be securely destroyed in Thailand to 
minimise risks of loss or theft. Signed consent forms will be retained securely in 
Thailand in locked storage in line with governance requirements; for administration, 
only a coded consent log without personal identifiers will be maintained by the 
research team. Identifiable information will remain in Thailand and will not be 
transferred. Only pseudonymised electronic data will be transferred from Thailand to 
QUB for analysis. Transfers will use encrypted storage and encrypted channels; files 
will then be uploaded to a secure QUB network location where they are stored and 
backed up, and any temporary copies created for transfer will be securely erased 
once integrity checks confirm successful upload. Explicit consent for cross-border 
transfer will be obtained via the study consent forms. No student contact details will 
be collected or retained; communication with participants will occur via the school’s 
designated channels. 
 
8. Data Analysis Strategy 
The data analysis will align with its primary aim of evaluating the feasibility, 
acceptability, and preliminary effectiveness of a Four-Week Compassionate Mindful 
Resilience (CMR) Intervention for secondary school students in Thailand.  
Feasibility 
outcomes—including 
recruitment, 
consent, 
attendance, 
retention, 
adherence, and acceptability—will be analysed using descriptive statistics. 
Preliminary effectiveness will be assessed through paired t-tests (or non-parametric 
equivalents where appropriate), quantifying changes in mindfulness, self-compassion, 
resilience, and WHO-5 well-being, plus self-reported substance-use indicators. Effect 
sizes (Cohen’s d) will estimate the magnitude of observed changes for future trials 
(Cohen, 1988). In addition to summaries including all enrolled participants, an 
exposure-based subset analysis will be reported for exploratory effectiveness only, 

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defined as participants who attended three or more of the four sessions; this threshold 
is analytic only and does not constitute a withdrawal criterion. 
Qualitative analysis will explore acceptability, perceived benefits, perceived changes 
in stress management and emotion regulation, barriers to engagement, and 
implementation considerations. Post-intervention focus groups with participants (and 
brief exit interviews for lower-attendance students) and facilitator debriefs will be 
audio-recorded, transcribed verbatim in Thai, translated into English, and analysed 
thematically using Braun and Clarke’s (2006) six-phase framework (reflexive thematic 
analysis). Coding will be undertaken by the primary researcher, with a second coder 
reviewing a subset of transcripts to enhance credibility; 10% of transcripts will be spot-
checked for fidelity. NVivo will support data management, and an audit trail will be 
maintained. Confidentiality will be preserved, all materials will be pseudonymised, and 
quotations will be de-identified in reporting. 
This study adopts a mixed-methods design, incorporating a process evaluation to 
explore the feasibility and acceptability of the intervention in a real-world school 
setting. Qualitative data from participants and facilitators will provide insights into 
implementation processes, contextual factors, and barriers to engagement. This 
process evaluation will complement quantitative outcomes and ensure a 
comprehensive understanding of both delivery and experience, thereby informing the 
design of a future randomised controlled trial. 
 
9. Ethical Considerations  
Ethical approval for this study will be obtained from the Faculty of Medicine, Life and 
Health Sciences Research Ethics Committee at Queen’s University Belfast, which 
oversees research involving human participants. The study will comply with UK 
research ethics policies and applicable data protection legislation and QUB 
governance policies. 
 
Given that data collection will take place in Thai secondary schools, the research team 
will also follow national ethical guidelines applicable to minors in Thailand, including 
obtaining dual consent (both parental consent and student consent), maintaining 
confidentiality, and ensuring access to emotional support if needed.  
 
A school counsellor will be on call and will intervene only in exceptional safeguarding 
circumstances that meet the school’s predefined thresholds (e.g., imminent risk or 
child-protection concerns). The counsellor will not attend routine sessions or access 
research data; any safeguarding records are held within school systems, separate 
from research data. If distress arises, the session may be paused and a welfare check 
within 24–48 hours will be completed in line with the Distress Protocol. 
 
Identifiable information will remain securely stored in Thailand and will not be 
transferred. Only pseudonymised electronic data may be transferred to Queen’s 
University Belfast using encrypted channels; explicit consent for cross-border transfer 
is obtained via the consent forms. The study will be conducted in compliance with 
applicable data-protection legislation and institutional policy. 
 
Participation is voluntary, and students have the right to withdraw at any time. Study 
data will be pseudonymised and securely stored, and results will be reported in 
aggregate to prevent identification of individuals. 
 

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Participants may request deletion of all their data (including coded/pseudonymised 
data) up to 7 days after the end of all data-collection activities; the exact calendar 
deadline will be communicated in the Participant Information Sheet. 
Publication and open access. Research outputs will be disseminated via academic 
publications and made publicly available through Queen’s Research Portal (open 
access): https://pure.qub.ac.uk/ 
 
10. Ethical Issues 
Conducting research with adolescents aged 16 to 18 in Thailand necessitates careful 
ethical consideration, particularly in relation to informed consent, stigma, social risks, 
confidentiality, and emotional well-being. In accordance with national research ethics 
regulations, adolescents in this age group are considered minors and therefore require 
a dual consent process. This includes obtaining both written consent from the student 
and informed consent from a parent or legal guardian prior to participation. These 
requirements are guided by the ethical standards set forth by the National Research 
Council of Thailand (NRCT) and are reinforced by school policies that prioritise student 
welfare. 
 
If distress occurs, the facilitator will pause the activity and contact the school 
counsellor, who is on call during all sessions. A welfare check will be completed within 
24–48 hours in line with the Distress Protocol. To ensure ethical integrity, this study 
will implement good research practices that uphold the dignity, autonomy, and 
psychological safety of participants. Additional safeguards specific to school-based 
research include: 
• 
Ensuring non-coercive recruitment, particularly given the hierarchical dynamics 
between teachers and students 
• 
Protecting participant confidentiality, especially in group-based sessions or 
small-class environments 
Providing access to appropriate psychological support, including referrals to 
school counsellors if any student experiences distress during the study 
 
10.1 Informed Consent and Voluntary Participation 
Since the participants are adolescents, obtaining informed consent will ensure their 
autonomy and maintain ethical research standards. In accordance with Thai national 
research ethics guidelines, adolescents aged 16 to 18 are considered minors and 
therefore require a dual consent process. This involves obtaining written informed 
consent from a parent or legal guardian, as well as written consent from the adolescent 
participant. This approach aligns with ethical standards for conducting research 
involving minors in Thailand (FERCIT, 2011; Thammasat University, n.d.). 
To minimise coercion, school personnel involved in recruitment will be briefed by the 
research team to use neutral and non-directive language. Students will be informed 
both verbally and in writing that participation is entirely voluntary and has no bearing 
on their academic performance or teacher expectations. The researcher will conduct 
an independent information session to reinforce the voluntary nature of the study and 
answer questions without the presence of authority figures applying any pressure. 
Participants will be assured that there will be no consequences to their academic 
performance or academic standing if they choose not to participate or to withdraw. 
 
 
 

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10.2 Minimising Stigma and Preventing Social Risks 
One important ethical consideration is the risk of being stigmatised, labelled, or socially 
excluded if adolescents are perceived as being at risk for potential mental health 
issues. To mitigate this, several strategies will be implemented. Initially, participants 
will be contacted in private to avoid unintentional disclosure of their participation. The 
study will be framed as a health and well-being programme and will avoid focusing on 
mental health issues to lessen the chances of stigma. In addition, the surveys and 
discussions from the study will consist of neutral language and supportive language 
to avoid stigmatising language.  The teachers and school staff participating in the study 
will receive education on confidentiality, stigma-sensitive communication, and ethical 
treatment of sensitive data. 
 
10.3 Confidentiality and Data Protection 
The confidentiality of the respondent is of utmost value in mental well-being research. 
Therefore, participants should feel safe and comfortable while providing any 
information. To maintain confidentiality, this research will adopt a host of precautionary 
measures.  Researchers will assign study codes to participants so that personal 
identifiers are not documented in the research data.  
 
All research datasets will be pseudonymised; identifiable information will be stored 
securely in Thailand and will not be transferred. Paper questionnaires will be scanned 
and verified in Thailand and then securely destroyed; signed consent forms will be 
retained securely in Thailand in locked storage as required by governance. 
Pseudonymised electronic data will be encrypted and transferred to Queen’s 
University Belfast (QUB) secure systems; temporary transfer copies will be erased 
once integrity checks are complete. Access to participants’ responses will be restricted 
to the research team and will not be shared with teachers, parents, or peers unless a 
serious safeguarding concern arises. Published results will be reported in aggregate, 
and any quotations will be de-identified so that individual participants cannot be 
identified. 
 
To help those who may suffer any emotional distress, necessary support will be 
provided. Some participants may feel emotional discomfort following discussions 
related to their personal experiences and risk factors. Participants may withdraw from 
the study at any stage without the requirement to provide justification. If they 
experience discomfort, they may choose to omit specific questions or discontinue their 
participation without any adverse consequences for their academic standing or well-
being. This withdrawal protocol has been formally discussed and approved by the 
school counsellor to ensure appropriate support structures are in place.  
Furthermore, participants experiencing emotional distress—whether related to the 
intervention or external factors—will be supported through a structured and ethically 
approved Distress Protocol (see Appendix 2). While researchers may not always be 
aware of emerging distress, participants will be informed of the availability of school-
based mental health services and external support contacts, including national 
helplines and online resources. 
Researchers will monitor for signs of distress, such as tearfulness, withdrawal, or 
marked emotional changes. If a significant concern arises, the session will be paused, 
grounding strategies offered, and a referral made to a designated school counsellor, 
who will assess the need for further support. All procedures follow the referral 

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pathways and safeguarding measures outlined in the protocol to ensure participant 
well-being is protected throughout the study (Appendix 2_Distress Protocol.docx). 
 
10.4 Ethical Oversight and Compliance 
This study will undergo ethical review and receive approval from the Faculty of 
Medicine, Life and Health Sciences Research Ethics Committee at Queen’s University 
Belfast (QUB MHLS), in accordance with international ethical standards such as the 
Declaration of Helsinki, American Psychological Association (APA) Ethical Guidelines, 
national research ethics regulations. In addition, the study will follow all policies of the 
school and institution to ensure welfare, privacy of students, and ethical conduct of 
research. The specific committee that monitors ethics will make sure the study is 
taking place properly, and any kind of ethics concern will be resolved as they arise. 
 
11. Stakeholder Involvement 
The participation of stakeholders is integrated into all stages of Phase 2 to ensure that 
the intervention is co-produced, contextually appropriate and responsive to the needs 
of the target population. Students, educators, school counsellors, administrators and 
policymakers will be actively involved in decision-making and implementation 
strategies.  The co-production process will be guided by Hart’s Ladder of Children’s 
Participation (1992), with the aim of positioning young people at levels of “partnership” 
and “delegated power” to ensure meaningful involvement (Hart, 1992). Their 
contributions will ensure that the intervention is practical, scalable, and sustainable in 
a Thai secondary school context. 
 
12. Dissemination and Publication 
Findings from each phase of the study will be disseminated through peer-reviewed 
journals, academic conferences, stakeholder briefings, and will be published in 
academic journals and deposited in the Queen’s University Belfast Research Portal 
(open access). 
The scoping review conducted in Phase 1 will be submitted to a journal on adolescent 
mental health or substance use prevention. Key findings will be presented at national 
and international conferences. We will provide a summary report to educators, 
policymakers, and mental health professionals for future intervention development. 
The outcomes of the co-production process in Phase 2 will be documented in a report 
that outlines the details of stakeholder contributions and adaptations to the 
intervention. The schools and health agencies will receive the findings and training 
materials for teachers and counsellors will be developed. At the conclusion of the 
study, end-of-study dissemination and dialogue workshops will be held with key 
stakeholders, including school administrators, teachers, school counsellors, 
representatives from the Ministry of Education, and youth participants. The event will 
present preliminary findings from the feasibility study and provide a platform to discuss 
the practical, ethical, and structural conditions for integrating the Four-Week CMR 
intervention into regular school settings. This session will also serve as an opportunity 
to gather feedback on adaptation needs and scalability, ensuring that future 
implementation strategies are aligned with the needs of both policy and practice. 
The outcomes garnered throughout Phase 3 of the feasibility study will be submitted 
for publication in a high-impact journal specialising in mindfulness and adolescent 
mental well-being. There will be policy briefings that will present findings to the 
education and health authorities to advocate for the implementation of the Four-Week 
(CMR) Intervention in existing mental health programmes. To disseminate the findings 

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to a larger audience, the engagement will include sharing lay summaries and 
infographics. 
To ensure the long-term sustainability of the Four-Week (CMR) Intervention in 
schools, this research will take a co-production approach whereby the Advisory Group 
will create resources and institutionalise CMR in the school system. A key component 
of sustainability will be integrating CMR training into teacher professional development 
to ensure long-term capacity building. To further evaluate the intervention, we plan to 
seek funding for a major RCT. The media and communications team at QUB will assist 
with dissemination strategies by developing a press release to engage audiences and 
policymakers. The steps will help to get strong evidence that will help in policymaking 
and to push for the systematic inclusion of CMR in mental health matters concerning 
youth. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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