Mindfulness-Based Intervention for Stress Reduction in Adult Singaporeans a Pilot Study
Phase: NA
Conditions: Mindfulness Meditation
Sponsor: Institute for Human Development and Potential (IHDP), Singapore

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STUDY PROTOCOL 
 
Mindfulness-Based Intervention for Stress Reduction in Adult Singaporeans 
(MISRAS)  
 
 
 
PROTOCOL VERSION:  
 
v1.0 
PROTOCOL DATE:  
ClinicalTrials.GOV: 
26/08/2024 
NCT06765889 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Table of Contents 
PROTOCOL SIGNATURE PAGE .............................................................................. 3 
1. BACKGROUND AND RATIONALE ...................................................................... 4 
2. AIMS AND HYPOTHESES .................................................................................... 5 
3. EXPECTED RISKS AND BENEFITS ..................................................................... 5 
4. STUDY POPULATION ........................................................................................... 6 
4.1. Number and nature of participants to be enrolled. .............................................. 6 
4.2. Criteria for Recruitment and Recruitment Process. ............................................. 6 
4.3. Inclusion criteria ............................................................................................... 6 
4.4. Exclusion Criteria ............................................................................................. 6 
4.5. Participant discontinuation criteria ................................................................... 7 
5. STUDY DESIGN, PROCEDURES AND METHODOLOGY ................................... 7 
5.1 Study design ..................................................................................................... 7 
5.2 Intervention ....................................................................................................... 7 
5.3.1. Features of the mindfulness intervention (experimental condition)................... 7 
5.3.2. Features of the sham meditation intervention (control condition) ..................... 8 
5.3.3 Concomitant medication .....................................Error! Bookmark not defined. 
5.4 Study measurements ........................................................................................ 8 
5.4.1 One-time measurement (start of the trial) .......................................................... 8 
5.5 Study procedures ............................................................................................ 10 
6. Ethics information .............................................................................................. 12 
6.2 Data protection ................................................................................................ 13 
7. SAFETY MEASUREMENTS ................................................................................ 13 
7.1 
Definitions ................................................................................................... 13 
7.2 Collecting, Recording and Reporting of Serious Adverse Events to A*STAR 
IRB ...........................................................................Error! Bookmark not defined. 
7.3 Safety Monitoring Plan .................................................................................... 13 
7.4. Complaint Handling ........................................................................................ 13 
8. SAMPLE SIZE AND STATISTICAL METHODS.................................................. 13 
8.1. Determination of Sample Size. ....................................................................... 13 
8.2. Statistical analyses. ....................................................................................... 13 
9. PUBLICATIONS .................................................................................................. 14 
10. RETENTION OF STUDY DOCUMENTS ........................................................... 14 
11. References ........................................................................................................ 15 
 

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PROTOCOL SIGNATURE PAGE 
 
 
 
Protocol Title: Mindfulness-Based Intervention for Stress Reduction in Adult 
Singaporeans (MISRAS)  
Protocol Version: v1.0 
Protocol Date: 26/08/2024 
 
Declaration of Investigator 
 
I confirm that I have read the above-mentioned protocol and its attachments. I agree 
to conduct the described study in compliance with all stipulations of the protocol and 
regulations.  
 
  
 
Principal Investigator Name:  Dr. Alessandro Sparacio 
                                                            
 
Principal Investigator Signature:  
 
                                                            
 
Date:  26/08/2024 
                                                            
 
 
 
 

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1. BACKGROUND AND RATIONALE  
Stress dramatically impacts people's lives, influencing how individuals think, behave 
and experience emotions (Aldwin, 2007; Lazarus & Folkman, 1984). Furthermore, 
stress is one of the major culprits in the development of pathologies such as 
depression and chronic anxiety (Yang et al., 2015). According to ‘The Ipsos survey 
for World Mental Health Day’ mental health has now become the primary concern for 
both Singaporeans and individuals worldwide when asked about the most significant 
healthcare issues in their respective countries. The top health concern among 
Singaporeans is mental health, with nearly half (46%) identifying it as the most 
pressing health issue in the country today, followed by cancer (38%) and stress 
(35%). The far-reaching consequences of this stress epidemic extend beyond 
personal well-being, impacting both the economic and healthcare sectors. Indeed, 
the symptoms of depression and anxiety are accountable for a substantial loss of 
2.9% of Singapore's GDP (Chodavadia et al., 2023). To proactively address the 
potential health repercussions linked to chronic stress, the development of stress 
reduction interventions becomes an imperative undertaking. 
Among these, mindfulness stands out. Defined by Jon Kabat-Zinn (2003, 2006) as 
‘paying attention in a particular way: On purpose, in the present moment, and 
nonjudgmentally,’ mindfulness offers a way to alleviate stress with interventions that 
can be self-administered. These approaches encompass different aspects such as 
fostering a non-judgmental attitude and embracing inner experiences, consistent with 
other mindfulness methods. However, compared to traditional protocols (such as 
Mindfulness Based Stress Reduction; MBSR; Kabat-Zinn, 2003), these interventions 
1) do not require the presence of an instructor, 2) are always available, and 3) are 
relatively cheap (Spijkerman et al., 2016). As these interventions show promise in 
effectively managing stress for a significant portion of the population, given their 
scalability, it is imperative to gain a thorough understanding of their efficacy. 
Recent meta-analyses have yielded inconsistent results concerning the presence of 
these effects for these interventions. One failed to uncover compelling evidence in 
their favour (Sparacio et al., 2024a), while others identified some evidence, albeit 
with a small effect size (Cavanagh et al., 2018; Taylor et al., 2021). These 
discrepancies may stem from various factors such as a medium to high risk of bias, 
limited sample size and inadequate statistical power of the included studies (Folk & 
Dunn, 2023). Furthermore, certain studies incorporated only passive control 
conditions potentially influencing the observed outcomes (Cavanagh et al., 2013) or 
lacked pre-registration, which raises concerns about the transparency and reliability 
of their findings (Lee et al., 2018). However, a recent pre-registered high-powered 
multi-site study (Nsites = 37; Nparticipants = 39) has filled most of these literature gaps, 
finding evidence that brief self-administered mindfulness exercises are more 
effective in reducing stress than an active control condition (Sparacio et al., 2024b). 
However, the study's choice of control condition (i.e., participants listening to a story) 
poses challenges in fully distinguishing the genuine impact of the intervention from 
potential demand characteristic effects (Nichols et al., 2008).  
Our objective is to initiate a preliminary investigation that will lay a solid foundation 
for a subsequent randomized controlled multi-site study. This upcoming research 
aims to determine whether the stress-reducing effect of mindfulness is genuine or 
influenced by participants' expectations when engaging in meditation. To achieve 
this, we will integrate self-reported data with objective assessments of the autonomic 
nervous system, specifically focusing on heart rate variability (HRV) as a measure of 
the stress response. Additionally, we will introduce a sham meditation control 
condition to further unravel the distinctions between genuine and demand effects. 

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This pilot study is necessary in laying the groundwork for a comprehensive 
investigation into mindfulness, aiming to uncover a cost-effective strategy for stress 
management that could benefit individuals in Singapore, especially those who might 
find conventional treatments financially prohibitive. Moreover, the success of this 
methodology has the potential to transcend local confines, offering an impactful 
solution to stress management that could resonate with a global audience. 
 
2. AIMS AND HYPOTHESES  
This pilot study seeks to assess the impact of a three-day mindfulness intervention 
on the stress response of Singaporean adults aged 21 or more. Specifically, we will 
anticipate a modest yet discernible reduction in stress levels compared to a control 
condition, represented by a sham meditation group. 
In addition to evaluating the effectiveness of the decentralized mindfulness 
intervention and its comparison with the sham meditation control group, this study 
will also incorporate an assessment of the credibility and usability of the survey-
based methodology employed. 
Participants' feedback regarding the clarity of survey instructions, ease of navigation, 
and overall user experience will be solicited through post-intervention 
questionnaires. Insights gleaned from participants' perspectives will inform 
refinements to the methodology, ultimately optimizing its utility for a fully 
decentralized study on mindfulness on a larger scale. 
 
3. EXPECTED RISKS AND BENEFITS 
The study's primary advantage lies in providing participants from the intervention 
group with access to a 3-day mindfulness intervention, potentially contributing to 
stress reduction. Although the study poses no significant risks for participants, a 
meta-analysis reviewed 36 randomized controlled trials (RCTs) from 7931 search 
records, including 25 that used Mindfulness-Based Stress Reduction (MBSR) and 11 
that used Mindfulness-Based Cognitive Therapy (MBCT), and found that both the 
mindfulness intervention group and the control group reported 19 adverse events 
each, accounting for 1% and 0.9% of participants, respectively. In the MBSR group, 
which had 1231 participants, only three studies (12.0%) reported six adverse events 
(0.49%) related to the intervention, with no significant adverse events recorded 
(Wong et al., 2018). In conclusion very few adverse events were reported in RCTs 
involving MBSR/MBCT, making mindfulness-based interventions generally 
considered to be safe.  
 
Data privacy  
The collection of health-related information via smartphone applications may pose a 
minor privacy risk in the event of device compromise or data transmission breaches. 
To mitigate these risks, all participant data will be encrypted to ensure the secure 
flow and storage of information. 
Only essential contact information, including phone numbers and email addresses, 
will be collected. Phone numbers will primarily be used to reimburse participants and 
to prevent duplicate survey submissions. At a designated point in the study, 
participants will be required to send a CSV file to the study coordinator. Upon 
receipt, the CSV file will be downloaded, and the associated email will be promptly 
deleted. This information will not be retained. Additionally, all phone numbers will be 
permanently deleted once data collection is complete. 
 

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4. STUDY POPULATION 
4.1. Number and nature of participants to be enrolled.  
Being this a pilot study, the target recruitment is set at 60 participants, aged 21 or 
older. 
  
4.2. Criteria for Recruitment and Recruitment Process. 
Participants will be recruited from the general Singaporean community. To 
streamline the recruitment process, we will utilize the broad reach of social media 
platforms, including Facebook, Instagram, and X (formerly Twitter), where we will 
post a detailed description of the study. 
Interested individuals will be directed to complete an online form (e.g. FormSG, 
Microsoft Forms etc), where they will answer questions related to the inclusion and 
exclusion criteria and provide a phone number for potential follow-up by the study 
coordinator. Those who meet the inclusion criteria will be contacted via phone (e.g. 
WhatsApp) by the study coordinator, who will guide them through the subsequent 
steps outlined in the procedure section.  
The study coordinator will review the form responses daily and will close the link 
once 60 participants have been confirmed as meeting the inclusion criteria.  
The trial involves a brief, fully anonymized online survey conducted over three 
consecutive days, with Day 1 and Day 3, requiring a commitment of approximately 
35 minutes and Day 2 a commitment of 25 minutes. Given the study's minimal risk, 
non-invasive nature, and the absence of medication administration, we will seek an 
exemption from the requirement for traditional written consent. 
To further enhance recruitment, we will collaborate with ASTAR's administrative 
team to notify potential participants in their database who have consented to receive 
research-related communications. Information about the study will also be shared 
through ASTAR's internal channels, in full compliance with digital platform 
regulations. 
 
4.3. Inclusion criteria 
Participants meeting all the following criteria will be included in the study:  
• Aged at least 21. 
• Possess a smartphone that can run the study applications with an internet 
access. 
• Fluent in the English language to understand the audio tracks, the study 
instructions and study assessments. 
• Sufficient vision and hearing to complete study procedures  
• Willing to commit to the study procedures  
 
All inclusion criteria will be assessed based on self-reported information during 
screening. 
 
 
4.4. Exclusion Criteria 
Participants meeting one or more of the following criteria below will not be included 
in the study: 
• Past (< 6 months prior to the study) or current major neurological and 
psychiatric disease. 
• Having meditated in the 6 months preceding the experiment. 

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• Participants who are currently taking psychoactive medications, including 
antidepressants, anxiolytics, hypnotics, and stimulants, or who have used 
these medications in the past week. 
• Members of the research team or their immediate family members. An 
immediate family member is defined as spouse, parent, child, or sibling, 
whether biological or legally adopted. 
 
All exclusion criteria will be assessed based on self-reported information during 
screening. 
 
 
4.5. Participant discontinuation criteria 
The participant has the right to withdraw from the trial at any time without facing any 
negative consequences.  
 
5. STUDY DESIGN, PROCEDURES AND METHODOLOGY 
5.1 Study design  
The research will adhere to a randomized, double-blind, 2-arm parallel-groups 
design. Participants will engage remotely from their home. The entire study duration 
is set at 3 days. 
 
5.2 Intervention  
Participants will be randomly allocated into one of two arms. Participants of the 
experimental group will listen for three consecutive days to a 10-minute mindfulness 
track once a day (experimental condition). Participants of the control group will listen 
for three consecutive days to a ‘sham meditation’ track once a day (control 
condition). The ‘sham meditation condition’ is an audio track that mimics the 
structure or elements of a meditation session but lack the authentic content or 
efficacy associated with genuine meditation practices.  
 
5.2.1. Features of the mindfulness intervention (experimental condition) 
The mindfulness intervention is comprised of three tracks of mindfulness practice 
adapted from a traditional Mindfulness-Based Stress Reduction (MBSR) protocol. 
The three mindfulness tracks incorporate essential elements of the mindfulness 
practice: a) Cultivating attentional stability by directing focus to present-moment 
bodily experiences (Moore et al., 2012), and b) fostering mindful meta-awareness by 
nonreactivity and nonjudgmentally observing and accepting experiences (Dahl et al., 
2015). These components are closely associated with successful mindfulness 
training and effective stress regulation according to a systematic review of Stein et 
al., 2020 that investigated the efficacy of different mindfulness components. See 
Appendix A to find the script of tracks that will be used in the current experiment.  
To enhance the protocol's validity, we conducted a focus group comprising 5 certified 
international mindfulness instructors. Their insights informed decisions on the 
duration, frequency, and content of the mindfulness tracks. Notably, one instructor 
that participated in the focus group recorded the audio tracks that will be used in the 
current study.  
 

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5.2.2. Features of the sham meditation intervention (control condition) 
We adopted a sham meditation practice aimed at being indistinguishable from 
meditation practice for newcomers (Zeidan et al., 2021). Ensuring the sham's 
structural equivalence was a pivotal consideration, with meticulous attention to 
matching the quantity and timing of instructions found in the mindfulness 
intervention. We underscored non-specific elements of meditation, like a soothing 
instructor's voice and terminology designed to create the expectation of authentic 
mindfulness meditation for those unfamiliar with the practice. 
However, the instructions deliberately excluded the training of the two fundamental 
cognitive/meta-cognitive processes crucial in mindfulness practice. This intentional 
omission involved 1) removing any attentional stability by providing participants with 
no specific point to anchor their attention and 2) offering no guidance on cultivating 
mindful meta-cognitive qualities of attention. Participants in the mindfulness group 
were taught to observe and accept their present-moment experience without 
judgment or reaction. In contrast, sham instructions offered no such guidance. 
 
5.3 Study measurements  
All questionnaires used in this study will be administered via a Qualtrics survey. 
5.3.1 One-time measurement (start of the trial) 
The following psychological and self-reported assessments will be taken at baseline. 
Participants will be starting the survey at home in a quiet place.  
Neuroticism subscale of the IPIP (IPIP-20; Goldberg et al., 2006) - 5 NEO 
domains. The scale consists of 20 items to assess the self-reported levels of 
neuroticism. Examples of items are “I often feel blue” or “I am filled with doubts about 
things” (answered on a five-point scale ranging from 1 = Very inaccurate to 5 = Very 
accurate). 
Resilience Scale 14 (RS-14; Miroševič et al., 2019) 
The RS-14 is a brief version of the Resilience Scale, comprising 14 items. Each item 
is rated on a 7-point Likert scale, ranging from 1 to 7. Example of items are “I usually 
manage one way or another” or “I am determined”. Higher resilience scores are 
associated with improved mental health, enhanced quality of life, and reduced levels 
of anxiety and depression. 
Demographics Participants will provide demographic information, including age, 
gender, ethnicity, type of smartphone used for the experiment, as well as its 
operating system (iOS or Android) and version. 
 
5.3.2 Pre and post measurements  
The Five Facet Mindfulness Questionnaire – Short Form (FFMQ-SF; Bohlmeijer 
et al. 2011). The scale is recommended for comparing pre and post interventions 
that employ mindfulness training. The scale measures 5 different components; 
Observing; the ability to notice and pay attention to the thoughts, feelings, and 
surroundings. Describing; the attitude to express the experiences in words, to 
describe thoughts and emotions. Acting with Awareness; How well they can act with 
intention and full awareness in their daily activities, rather than on autopilot. Non-
judging of Inner Experience; tendency to avoid judging their thoughts and emotions 
as good or bad. Non-reactivity to Inner Experience; tendency to experience thoughts 
and emotions without reacting impulsively. However, recent hierarchical confirmatory 
factor analysis indicates a preference for a four-factor FFMQ (excluding the 'observe' 
subscale) in non-meditative samples, as opposed to the traditional five-factor score 
(Gu et al., 2016). Consequently, the analysis will focus on four facets: Describing, 

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acting with awareness, non-judging, and non-reactivity. Examples of items are “I can 
describe my feelings well” or “I can easily talk about my thoughts and opinions” 
(answered on a five-point scale ranging from 1 = never or very rarely to 5 = Very 
often or always true). We will take this assessment at baseline and at the end of the 
experiment. 
 
Repeated measurements (day 1, day 2, day 3) 
State Trait Anxiety Inventory (STAI-6; Marteau TM, Bekker) The STAI-6 is a 
validated short-form version of the 40-item State-Trait Anxiety Inventory (STAI), 
consisting of 6 items that measure current anxiety symptoms using a 4-point Likert 
scale. Example items include statements such as "I feel calm" and "I am tense." The 
STAI-6 will be administered twice daily: once before and once after listening to each 
audio track. 
Ecological Momentary Assessment – (EMA) Participants will indicate their current 
state on a 7-point Likert scale, with the options "Very Bad," "Bad," "Fairly Bad," 
"Same as Before," "Fairly Good," "Good," and "Very Good," encoded as [1, 2, 3, 4, 5, 
6, 7], respectively. The following questions will be posed to assess various 
psychological and physical states: 
 
• 
"Right now, I feel mentally sharp" – to assess perceived cognitive ability. 
• 
"Right now, I feel fatigued" – to assess fatigue and exhaustion. 
• 
"Right now, I feel stressed" – to assess stress levels. 
• 
"Right now, I feel nervous" – to assess nervousness and tension. 
• 
"Right now, I feel depressed" – to assess depressive symptoms. 
• 
"Right now, I am in a good mood" – to assess positive affect and joy. 
• 
"I slept well last night" – to assess subjective sleep quality. 
 
Ecological Momentary Assessment (EMA) will be conducted twice daily, immediately 
following each administration of the STAI-6 questionnaires. 
 
Heart Rate Variability. To assess parasympathetic activation, participants' heart 
rate variability (HRV) will be analyzed. HRV is widely recognized as a sensitive 
marker of stress, regulated by the autonomic nervous system in response to 
stressors (Goldberger et al., 2001). Participants will monitor their HRV using the 
'Camera Heart Rate Variability' smartphone app, which employs 
Photoplethysmogram (PPG) technology. Notably, smartphone apps utilizing PPG for 
heart rate measurement have shown consistency with validated methods such as 
electrocardiography (ECG) in adult populations during resting states (Guede-
Fernández et al., 2020). 
Participants will assess their HRV values seven times over the course of the trial 
(from Day 1 to Day 3). Participants will be instructed to place their index finger over 
the smartphone's camera and flash, ensuring both are fully covered. They will hold 
their finger in place for one minute to allow the device to record their heart rate 
variability (HRV). Upon completion, the HRV measurement will be saved in the app's 
local folder. If the finger placement is inadequate, resulting in poor assessment 
quality, the app will indicate that the CSV file has not been created. In such cases, 
participants will be asked to repeat the assessment up to two more times. If they are 
still unable to obtain a valid measurement after the third attempt, they will be 
instructed to proceed to the next section of the survey. 

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Participants will then send the corresponding CSV file via email to the study 
coordinator using a feature included in the app, following the instructions provided at 
the beginning of the experiment. To ensure that HRV data is not lost, participants will 
also self-report the corresponding values in the Qualtrics survey.  
The first HRV measurement will serve as testing purposes and will be taken 
immediately after the survey that will prompt participants to go to a quiet place just 
after the start of the experiment. The additional HRV measurements will be taken 
twice daily, immediately following the completion of each Ecological Momentary 
Assessment (EMA). 
 
One-time measurement (end of the trial) 
Usability of the intervention to assess the usability of the current pilot trial, a set of 
questions will be asked to assess the participants' experiences with the mindfulness 
and sham meditation tracks in terms of ease of use, clarity of instructions, relevance 
to daily life, engagement levels, comfort, perceived efficacy, willingness to continue 
usage, any technical issues encountered, and suggestions for improvement.  
Perceived Awareness of the Research Hypothesis (PARH; Rubin 2016) is a 
four-item quantitative self-report tool designed to assess the possible impact of 
demand characteristics in research settings. Its purpose is to assist in challenging 
the notion that observed effects can be attributed to demand characteristics. 
Participants provide their responses to these statements using a 7-point Likert-type 
scale, where the options range from strongly disagree (1) to strongly agree (7). 
Examples of statements include: “I was aware of the researchers' objectives in this 
study” and “I was uncertain about the researchers' intentions in conducting this 
research”. 
Expectancy and credibility of the intervention  
To assess expectancy, we will use a single item adapted from the 
Credibility/Expectancy Questionnaire (Devilly & Borkovec, 2000) during the final 
phase of post-intervention testing: “On a scale from 0 to 10, How effective do you 
believe the meditation training has been in alleviating stress? (0 = Not at all 
successful, 10 = Extremely successful).” 
To evaluate credibility, participants will respond to a two-part question: “If you were 
informed that you might have received either meditation training or control training, 
which type do you believe you received? (Meditation, Control)”. “How confident are 
you in your answer? (0 = Not at all confident, 10 = Extremely confident)”. 
 
5.4 Study procedures 
Participants expressing interest will first complete an initial online screening form 
(e.g., via FormSG or Microsoft Forms), containing non-sensitive questions to assess 
eligibility based on study criteria such as English proficiency, age, meditation 
experience, vision and hearing capabilities, willingness to commit to the study 
procedures, and any relation to A*STAR research team members. Participants will 
also provide their phone number, which will be used to notify them of their eligibility 
status. The phone number will be retained until the end of data collection to prevent 
repeat participation, facilitate the delivery of study materials, and ensure 
compensation via e-vouchers. The study coordinator will check whether a mobile 
number has been previously used and stop participants if a duplicate number is 
detected. 
Once the study coordinator reviews the responses daily, eligible participants (I.e., 
those meeting inclusion and exclusion criteria and those who provided a phone 
number not previously entered in the survey), will receive a standardized text 

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message (e.g., via WhatsApp) confirming their preliminary eligibility. For ineligible 
participants, their collected data will be discarded. If eligible, participants will be 
informed that the study will begin within three weeks. Upon the recruitment of the 
20th participant or at the end of the third week, the coordinator will notify the cohort, 
instructing them to start the study within two days. The study will consist of three 
cohorts of 20 participants each. If fewer than 60 participants are recruited after the 
third cohort, an additional cohort will be organized to reach the target number. 
 At this point, participants will receive a message containing the following: a link to 
access the Qualtrics survey, an access code (which serves as an anonymous 
identifier), and a link to instructions for downloading the 'Camera Heart Rate 
Variability' app, used for heart rate variability (HRV) measurement. The instructions 
will detail how to take measurements and submit the generated HRV.csv data files to 
the study team. Participants will also receive a code to download the app for free. 
They will be advised to complete the survey each day at the same time, between 9 
am and 9 pm. 
The Qualtrics link contains the written informed consent form and the actual 
experiment. Participants will be able to review all relevant information about the 
study and either accept or decline to participate. If they do not provide consent, they 
will be opted out of the study. If consent is provided, participants will proceed to the 
second screening, which involves answering additional questions about their use of 
concomitant medication. If they meet the criteria for this stage, they will proceed to 
answer questions about any neurological or psychiatric conditions. If any of the 
screening criteria are not satisfied at any point, the study will automatically terminate. 
Once consent and second screening are complete, participants will then be 
instructed to move to a quiet environment where they will not be disturbed for the 
next 35 minutes. They will be asked to download the ‘Camera Heart Rate Variability’ 
app and take an initial HRV measurement for testing purposes. Participants will then 
submit the generated CSV file to the study coordinator via Whatsapp and self-report 
their rMSSD values in the Qualtrics survey. Participants are instructed to label their 
CSV files using their anonymous identifier provided by the study coordinator via 
Whatsapp at the start. Afterward, they will complete a series of questionnaires, 
including the 20-item IPIP scale, the RS-14, the FFMQ, and various demographic 
questions such as age, gender, ethnicity, smartphone type used during the 
experiment, and its operating system (iOS or Android) and version. Pre-intervention 
assessments of STAI-6, EMA will also be conducted. They will then use the ‘Camera 
Heart Rate Variability’ app to measure HRV, submit the generated CSV file to the 
study coordinator, and self-report their rMSSD values in the Qualtrics survey, as 
outlined in the instructions. 
Participants will then be randomly assigned by the Qualtrics engine to either the 
experimental group, which listens to a mindfulness audio track, or the control group, 
which listens to a ‘sham meditation’ track. Both tracks are embedded within the 
Qualtrics survey. Participants cannot skip this portion of the survey for 10 minutes, 
ensuring they listen to the entire 10-minute audio track. Afterward, participants will 
be asked to sit quietly for three minutes without engaging in any activities. This 
pause is necessary because, some of the audio track encompasses the application 
of mindfulness principles while performing a routine activity (e.g., brushing teeth) 
during the listening of a mindfulness track. Although the movement involved in this 
activity is minimal, we want participants to sit still for three minutes to avoid 
introducing any confounding variables in the subsequent HRV assessments. The 
survey will be programmed to remain stuck during this period to prevent participants 
from skipping this step. 

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Following the quiet period, participants will complete post-intervention assessments 
for STAI-6, EMA and HRV. Participants will be thanked and instructed to reopen the 
survey link the following day, ideally at the same time between 9am and 9pm. On 
Day 2, they will complete the same pre-intervention assessments (STAI-6, EMA and 
HRV), listen to a different audio track, either mindfulness or sham meditation, 
depending on their group allocation, sit for three minutes, and then complete the 
post-intervention assessments mirroring Day 1.On Day 3, participants will undergo 
the same procedure as Day 2 but will listen to another audio track (mindfulness or 
sham). Additionally, they will complete the FFMQ, answer questions about their 
expectations of the intervention, its credibility, the PARH scale, and the usability 
questionnaire. Finally, participants will be thanked for their participation in the study 
and debriefed. 
 
6. Ethics information 
This study will be conducted in accordance with the ethical principles outlined in the 
Declaration of Helsinki and in compliance with applicable regulatory requirements. 
The final study protocol, along with the latest version of the Participant Information 
and Consent Form, will receive written approval from the A*STAR Institutional 
Review Board (A*STAR IRB) before any participants are enrolled. 
Participants who express interest in the study will first complete an initial screening, 
where non-sensitive questions will be asked to assess their English proficiency, age, 
meditation experience, vision and hearing capabilities, willingness to commit to study 
procedures, and any relation to A*STAR research team members. If participants do 
not meet the inclusion/exclusion criteria at this stage, their responses will be 
promptly disposed of to ensure anonymity. If they qualify, they will be sent a link to 
the Qualtrics platform, which will contain the written informed consent form and the 
actual experiment. 
Given that the study poses minimal risk to participants, does not involve the use of 
medication, and is not expected to result in any incidental findings, we will implement 
a written informed consent process. Participants will be able to review all relevant 
information about the study and provide their consent through the online survey used 
for the experiment. A study coordinator and witness will not be present during the 
consent process. If participants choose not to consent, they will be opted out of the 
study. Those who do provide consent will be asked additional questions regarding 
their use of concomitant medication. If the participant satisfies this inclusion criteria 
he will pass at the next window of the survey where he will answer a question related 
to neurological or psychiatric conditions. If any screening criteria are not satisfied, 
the study will automatically terminate at that point. 
As part of standard ethical procedures, participants will provide their consent by 
completing a written form administered through the online survey platform. We will 
collect participants' phone numbers to facilitate compensation and to prevent multiple 
survey submissions. All phone numbers will be deleted at the end of the trial. 
Although participants will email the study coordinator with the generated CSV file, 
their email addresses will not be collected, and once the CSV file is downloaded, the 
email will be permanently deleted. All other data collected will be de-identified to 
protect participants' anonymity. 

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6.2 Data protection 
Data will be processed in accordance with the Data Protection Act 2018 and the 
General Data Protection Regulation 2016 (GDPR). All information collected will be 
kept strictly confidential. The data we will collect for this study will be made 
anonymous from the start. All electronic data will be stored on password-protected 
computers belonging to the research team. The researchers will abide by local data 
protection laws when collecting personal data. All research data will be captured as 
de-identified (coded) electronic data. A designated folder will be created for the study 
team to store the research data files on an SOD (Storage on demand) space. The 
A*STAR SOD is created on secured A*STAR servers and is designed with strict 
access controls. Once the data is no longer necessary (maximum of 10 years), it will 
be appropriately discarded (e.g., deleted off from A*STAR’s SOD). 
 
7. SAFETY MEASUREMENTS 
7.1 
Definitions 
Serious adverse event (SAE) in relation to human biomedical research means any 
untoward medical occurrence because of any human biomedical research which: 
• Results in or contributes to death 
• Is life-threatening 
• Requires inpatient hospitalization or prolongation of existing hospitalization 
• Results in or contributes to persistent or significant disability/incapacity 
• Results in or contributes to a congenital anomaly /birth defect 
• Results in the transmission of a communicable disease 
• Results in any misidentification or mix-up of any type of tissue, gametes or 
embryo 
• Any other events that may be prescribed 
 
7.2 Safety Monitoring Plan 
The Principal Investigator (PI) will collect feedback from participants at the end of the 
trial. Given that this study involves minimal risk to participants and does not include 
the use of medications, we do not plan to systematically record adverse events. 
Therefore, we do not anticipate significant risks of adverse events. 
 
7.4. Complaint Handling  
Any feedback from participants of each site will be taken seriously and concerns will 
be brought up to the PI to follow up. 
 
8. SAMPLE SIZE AND STATISTICAL METHODS  
 
8.1. Determination of Sample Size. 
 
Since this is a pilot trial, we aim to recruit 60 participants to account for a ~20% 
dropout rate, ensuring we meet our target of at least 50 participants. 
 
8.2. Statistical analyses. 
 
Our confirmatory statistical analyses will include: 
 
- 
Bayesian mixed-effects models to investigate the longitudinal changes in self-
reported stress measured via STAI-6. The model will have STAI-6 as the 

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dependent variable, with 'Group' (mindfulness intervention or control), 'Day' (1 
to 3), and their interaction term as independent variables. Participant ID will 
be used as a random intercept to control for individual differences. A BF10 
greater than 1 will indicate slightly positive evidence supporting the 
effectiveness of the mindfulness condition over the control condition in stress 
reduction. 
 
We will also conduct the following exploratory statistical analyses: 
 
- 
A Bayesian mixed-effects model to assess longitudinal changes in HRV, using 
HRV as the dependent variable and 'Group', 'Day' (1 to 3), and their 
interaction as independent variables. Participant ID will again serve as a 
random intercept. A BF10 greater than 1 will suggest positive evidence for the 
mindfulness intervention's effectiveness compared to the control. 
 
- 
An additional Bayesian mixed-effects model will analyze longitudinal changes 
in HRV, with the dependent variable being HRV (calculated by the difference 
in pre- and post-meditation HRV scores) and independent variables including 
'Group', 'Day' (1 to 3), and their interaction. Participant ID will account for 
individual variability in baseline HRV levels. 
 
- 
Correlational analyses to explore the relationship between changes in 
mindfulness scores and stress levels, as well as between HRV changes and 
stress levels. 
 
- 
Descriptive statistics to summarize baseline participant characteristics, such 
as neuroticism, RS-14 scores, FFMQ scores related to mindfulness training, 
and demographic details. 
 
- 
Analysis of responses regarding the intervention's credibility and participant 
awareness of the research hypothesis to assess equal credibility of the 
intervention for the mindfulness condition and the sham. 
 
9. PUBLICATIONS 
This pilot study will adhere to A*STAR publication policy and will be registered in a 
public registry (www.clinicaltrials.gov) and the Open Science Framework 
(www.osf.io). 
 
10. RETENTION OF STUDY DOCUMENTS 
Documents pertaining to the study, such as protocols, regulatory papers, participant 
logs, safety reports, financial and contractual records, data collection sheets, and 
case report forms, will be organized into distinct folders known as Investigator Site 
Files. These files will be securely stored in designated locked cabinets and/or rooms, 
ensuring access is restricted to authorized study personnel exclusively. Authorized 
authorities will have the privilege to inspect and copy these records. Upon 
completion of the study or when the data is no longer required (up to a maximum of 
10 years), appropriate disposal procedures will be implemented, such as deleting the 
data from A*STAR's secure storage system (SOD). 
 

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11. Appendix A 
 
Day 1 
 
Intro (2 min) 
 
We live our life in such a hurry, that we often allow moments to just pass us by. 
Most of the time, the mind is preoccupied, and we are only paying partial attention to 
everything. 
We tend not to be very present with our environment, with others, and especially with 
ourselves. 
 
Paying attention is important for our wellbeing. 
It is only with attentiveness that we know how we are choosing to interact with life 
itself. 
It is only with attentiveness that we realise, most of the time we are unnecessarily 
dwelling in the past and the future. 
When the mind is only concerned with the past and future, we miss out on what is 
going on in the present. 
We miss the joyful, magical moments of every day life. 
We miss our connectedness with people and this world we inhabit. 
We ignore signs in the mind and the body telling us that we need change, that we 
need to live better. 
 
So let's practice being present today, by tuning in to our experience from moment to 
moment. 
Let's pay attention to everything that is going on, inside and outside of us. 
 
 
Practice (8 min) 
 
Let's begin with a sitting posture. If you are seated on a chair, make sure that your 
legs are uncrossed, and your feet are planted flat on the floor, for stability. 
Take a few moments to settle the body into stillness. 
Invite a sense of gentleness and lightness to this practice, by softening your gaze. 
 
Take a deep breath in, and as you breathe out... 
Allow your awareness to take in the visuals of your surroundings. 
Notice colours, shapes, patterns and textures around you. 
Get a sense of the space in front of you. The space to your right. And to your left. 
The space behind you. 
 
One moment at a time, inviting presence to the sense of sight. 
 
(long pause) 
 
And now allow the eyes to gently close if you like. 
When you're ready, open your awareness to the presence of sounds. 
Allow the ears to just receive sounds from your environment. 
 

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If there are sounds present, just know that sound is present. 
If there are no sounds present, just know that no sound is present. 
 
One moment at a time, inviting presence to the sense of hearing. 
 
(long pause) 
 
And now bring your attention to this body in this sitting posture. 
Get a sense of the whole body just sitting and resting in this stillness. 
Invite curiosity to what the body may be experiencing from moment to moment. 
 
You might bring your attention to the immediate space around the body 
How the air comes in contact with the skin - is there temperature in the air? 
Notice how the body is coming in contact with the chair or what you are resting on 
Maybe also notice the way the body is breathing 
 
One moment at a time, inviting presence to the sense of touch. 
 
See if you can be with the body as it is, without the need to change anything in your 
experience. 
 
Full awareness of the body, from moment to moment. 
 
(long pause) 
 
From time to time, you may notice your attention getting pulled away by sounds 
around you. 
 
When that happens, just know that sound is here, and invite your attention back to 
the body. 
 
Perhaps your attention gets pulled away by thoughts. 
And just know that thought is here, and gently guide your attention back to the body. 
 
(long pause) 
 
One moment at a time. 
 
(long pause) 
 
Now let's bring this practice to an end, by taking a deep breath in. 
As you breathe out, gently opening or widening the eyes. 
 
Have a lovely day! 
 
(End) 
 
Day 2 
 
Intro (2 min) 
 

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Let's learn to be curious today. 
When we invite curiosity to any moment of our experience, we begin to connect 
more deeply with ourselves and the world. 
When we are curious, we are more likely to stay present. 
With curiosity we approach an activity with interest and alertness, rather than allow 
the mind to operate on autopilot or habitual tendencies. 
 
We are so used to judging everything that comes into our awareness, and jumping to 
conclusions about how things should or should not be. 
Curiosity helps us to see things as they are. 
When we bring in curiosity, we suspend any unnecessary judgement and we 
become more open to new perspectives and possibilities. 
 
The practice of curiosity should begin in everyday life. 
It requires us to turn towards the whole of our experience and acknowledge what is 
happening, even when we have experienced it many times before. 
We learn to take a step back and simply watch and observe ourselves. 
 
Today, we are going to cultivate curiosity as we brush our teeth. 
You must have brushed your teeth countless times in your life, and this time you are 
invited to be curious about the way you engage in this routine activity. 
Allow this audio to play in the background, and simply follow along the guidance as 
best as you can while brushing your teeth. 
If you have a different way of cleaning your teeth, feel free to adapt the instructions, 
with the understanding that when we brush our teeth with curiosity, we should be 
fully present with the entire experience. 
 
 
Practice (8 min) 
 
Let's start by paying attention to how you are preparing the toothbrush and 
toothpaste. 
 
(pause) 
 
As you begin to brush your teeth, engage with the experience by inviting awareness 
to your five senses. 
 
How does the toothpaste taste? You might notice sensations of mintiness and the 
taste of sweetness. 
And how the toothpaste begins to foam inside your mouth. 
Stay with this experience for a few moments, and just observe. 
 
(pause) 
 
Are there also thoughts arising in the mind? Is your attention being pulled away by 
sounds or events happening around you? 
Whenever you find yourself getting distracted, simply bring your attention back to the 
experience of brushing your teeth. 
 
(pause) 

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With curiosity, pay attention to the movements of your arm and hand as you brush 
the teeth. 
 
How is the brush coming in contact with the inside of the mouth? How do the bristles 
feel against the teeth and the gums? 
You might even bring awareness to the sounds of brushing. 
 
(pause) 
 
How do you know the teeth are now clean enough, and you are ready to rinse and 
gargle? 
 
(pause) 
 
And now when you're ready, tune in to the sound of the tap water running. 
Invite curiosity to the temperature of the water with your hand and fingers. 
Is there coolness? Is there warmth? 
 
(pause) 
 
As you rinse and gargle, turn your attention inwards to notice the sounds and 
sensations of gargling. 
Notice how many times you rinse the mouth. 
 
(pause) 
 
And when the teeth feels clean, maintain your awareness on the way you are 
bringing this activity to an end. 
 
(pause) 
 
Have a lovely day! 
 
(End) 
 
Day 3 
 
Intro (2 min) 
 
Have you ever paid much attention to your breathing? 
Usually not, at least not until we are feeling short of breath. 
 
But what might you notice when you intentionally bring awareness to your body 
breathing? 
Nothing much, I suppose, and this is what today's practice is all about. 
We are not looking for anything special or unusual in the breath. 
We simply invite curiosity to how the body is breathing, and learn to observe the 
breath just the way it is. 
 

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We allow each breath that comes into our awareness to remind us that we are 
present, we are in the here and now. 
 
When we bring awareness to the breath, we might notice that we don't actually like 
the way we are breathing, and we may want to change the breathing experience or 
try to control our breath and breathe a certain way. 
No need for any of that. Not for our practice today. 
 
Keep in mind that there is nothing we need to do to the breath. There is no need to 
deepen the breath or lengthen the breath. 
We are simply going to cultivate curiosity by gently turning our attention towards the 
natural breath. 
And see if you can bring in a whole lot of curiosity to what you are observing. Watch 
how each breath enters the body, and then leaves the body. Trust that the body 
knows how to breathe on its own. 
 
 
Practice (8 min) 
 
Have a seat somewhere, adopting a wakeful sitting posture. You may choose to 
close your eyes for this practice, or leave them open, resting your gaze on the floor 
in front of you.Take a few moments to settle the body into stillness. 
 
(pause) 
 
And now bring your attention to your body in this sitting posture, and with curiosity 
notice the way the body is breathing in and breathing out. 
 
(long pause) 
 
You may choose to rest your attention on a smaller part of the body, where you best 
feel the sensations of breathing, like at the nose - noticing the air flowing in and out 
through the nostrils, 
 
(pause) 
 
Or you might pay attention to the movements of the breath at the chest, at the 
shoulders, or at the belly - rising, expanding as you breathe in, and releasing as you 
breath out. 
 
(long pause) 
 
Notice if there’s a tendency to want to deepen or lengthen the breath in any way, and 
see if it's possible to allow the breath to just be natural. 
 
(pause) 
 
We’re not trying to control the breath here, we’re just learning to rest with the natural 
flow of the breath. 
 
(pause) 

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Awareness of one breath at a time. 
Simply follow the movements of the breath, the physical sensations of the breath. 
 
(long pause) 
 
Full awareness of the in breath. Full awareness of the out breath. 
 
One breath at a time. 
 
(long pause) 
 
From time to time, you might notice your mind getting distracted by sounds aroud 
you, or by your own thoughts. Each time your attention wanders off, simply bring it 
back to your breath in the body. 
 
(pause) 
 
Rest your attention on the body, breathing in, breathing out. 
 
(pause) 
 
If you notice any judgmental thoughts about how restless the mind is, simply know 
that these thoughts come and go, just like any other thoughts you’ve had. 
 
So simply invite your attention back to the breath in the body. 
 
(long pause) 
 
Over and over again, bringing your attention back to the breath. 
 
Gently paying attention to this experience, one breath at a time. 
 
(long pause) 
 
Now when you’re ready to end this practice, take a deep breath in through the nose, 
and exhale slowly through the mouth. And gently opening or widening your eyes. 
 
Have a lovely day! 
 
(End)