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Background: Mindfulness-based programs hold promise for improving cardiovascular health (e.g. physical activity, diet, blood pressure). However, despite theoretical frameworks proposed, no studies have reported qualitative findings on how study participants themselves believe mindfulness-based programs improved their cardiovascular health. With an emphasis on in-depth, open-ended investigation, qualitative methods are well suited to explore the mechanisms underlying health outcomes. The objective of this qualitative study was to explore the mechanisms through which the mindfulness-based program, Mindfulness-Based Blood Pressure Reduction (MB-BP), may influence cardiovascular health., Methods: This qualitative study was conducted as part of a Stage 1 single arm trial with one-year follow-up. The MB-BP curriculum was adapted from Mindfulness-Based Stress Reduction to direct participants' mindfulness skills towards modifiable determinants of blood pressure. Four focus group discussions were conducted (N = 19 participants), and seven additional participants were selected for in-depth interviews. Data analysis was conducted using the standard approach of thematic analysis. Following double-coding of audio-recorded transcripts, four members of the study team engaged in an iterative process of data analysis and interpretation., Results: Participants identified self-awareness, attention control, and emotion regulation as key mechanisms that led to improvements in cardiovascular health. Within these broader themes, many participants detailed a process beginning with increased self-awareness to sustain attention and regulate emotions. Many also explained that the specific relationship between self-awareness and emotion regulation enabled them to respond more skillfully to stressors. In a secondary sub-theme, participants suggested that higher self-awareness helped them engage in positive health behaviors (e.g. healthier dietary choices)., Conclusion: Qualitative analyses suggest that MB-BP mindfulness practices allowed participants to engage more effectively in self-regulation skills and behaviors lowering cardiovascular disease risk, which supports recent theory. Results are consistent with quantitative mechanistic findings showing emotion regulation, perceived stress, interoceptive awareness, and attention control are influenced by MB-BP., Competing Interests: The authors have read the journal’s policy and have the following potential competing interests: EC is the Director of the Mindfulness Center at Brown University. The Mindfulness Center, a non-profit entity, has an Education Unit that provides mindfulness-based program delivery to the general public for fees. Dr. Loucks’s salary is not tied to quantity, or content, of programs offered through the Mindfulness Center, and this therefore does not alter our adherence to PLOS ONE policies on sharing data and materials. There are no patents, products in development or marketed products associated with this research to declare.

Background and Objectives: Impacts of mindfulness-based programs on blood pressure remain equivocal, possibly because the programs are not adapted to engage with determinants of hypertension, or due to floor effects. Primary objectives were to create a customized Mindfulness-Based Blood Pressure Reduction (MB-BP) program, and to evaluate acceptability, feasibility, and effects on hypothesized proximal self-regulation mechanisms. Secondary outcomes included modifiable determinants of blood pressure (BP), and clinic-assessed systolic blood pressure (SBP)., Methods: This was a Stage 1 single-arm trial with one year follow-up. Focus groups and in-depth interviews were performed to evaluate acceptability and feasibility. Self-regulation outcomes, and determinants of BP, were assessed using validated questionnaires or objective assessments. The MB-BP curriculum was adapted from Mindfulness-Based Stress Reduction to direct participants' mindfulness skills towards modifiable determinants of blood pressure., Results: Acceptability and feasibility findings showed that of 53 eligible participants, 48 enrolled (91%). Of these, 43 (90%) attended at least 7 of the 10 MB-BP classes; 43 were followed to one year (90%). Focus groups (n = 19) and semi-structured interviews (n = 10) showed all participants viewed the delivery modality favorably, and identified logistic considerations concerning program access as barriers. A priori selected primary self-regulation outcomes showed improvements at one-year follow-up vs. baseline, including attention control (Sustained Attention to Response Task correct no-go score, p<0.001), emotion regulation (Difficulties in Emotion Regulation Score, p = 0.02), and self-awareness (Multidimensional Assessment of Interoceptive Awareness, p<0.001). Several determinants of hypertension were improved in participants not adhering to American Heart Association guidelines at baseline, including physical activity (p = 0.02), Dietary Approaches to Stop Hypertension-consistent diet (p<0.001), and alcohol consumption (p<0.001). Findings demonstrated mean 6.1 mmHg reduction in SBP (p = 0.008) at one year follow-up; effects were most pronounced in Stage 2 uncontrolled hypertensives (SBP≥140 mmHg), showing 15.1 mmHg reduction (p<0.001)., Conclusion: MB-BP has good acceptability and feasibility, and may engage with self-regulation and behavioral determinants of hypertension., Competing Interests: Dr. Loucks is Director of the Mindfulness Center at Brown University. The Mindfulness Center, a non-profit entity, has an Education Unit that provides mindfulness based program delivery to the general public for fees. However, Dr. Loucks’s salary is not tied to quantity or content of programs offered through the Mindfulness Center. Dr. Loucks is a practicing Buddhist, and while the mindfulness elements of MBSR and MB-BP have roots in Buddhist philosophy, the intervention is designed for use in secular health settings, and does not encourage any particular religion. Additionally, conditions were put in place to limit the potential bias of Dr. Loucks’s religious affiliation on study data interpretation. For example, the primary outcomes were preregistered on ClinicalTrials.gov. Dr. Loucks did not have access to the data file. He also did not perform the statistical analyses which were performed by an independent data analyst (Y.L.), or the qualitative coding and analyses that were led by three trained co-authors (W.N., A.W., J.W.). The data have been made publicly available using the OpenScience Framework. Dr. Britton is an MBSR and Mindfulness-Based Cognitive Therapy teacher. She has received payment to provide trainings on best practices for harms monitoring, measurement, and management. This does not alter our adherence to PLOS ONE policies on sharing data and materials.