Nature-based Contemplation and Spiritual Well-being Among Adults With Moderate Prolonged Grief Symptoms

Lead sponsor

University of Twente is the lead sponsor of 16 studies on the registry; 6 are open to participants now.

Study arms

• Experimental
  Nature-based contemplation

  10 minutes walking to a chosen natural location, 10 minutes guided contemplation practice, 10 minutes walking back.

  Behavioral: Nature-based contemplation

• Active comparator
  Noticing-nature

  walk in nature for 30 minutes per day and pay attention to how the natural objects/scenes they encounter in their daily surroundings make them feel over the 14-day period.

  Behavioral: Noticing-nature

• No intervention
  Waitlist

Interventions

• BehavioralNature-based contemplation

  The intervention consisted of a daily 30-minute self-guided practice structured in three parts: (1) participants first walked mindfully for 10 minutes in a natural environment of their choosing (e.g., local park, forest, garden), (2) upon reaching a suitable location, they engaged in a 10-minute guided contemplative practice, and (3) concluded with a 10-minute mindful walk back.

• BehavioralNoticing-nature

  Participants allocated to the noticing-nature active control group will be instructed to walk in nature for 30 minutes per day and pay attention to how the natural objects/scenes they encounter in their daily surroundings make them feel over the 14-day period.

Primary outcomes

1. Spiritual well-being measured by Spiritual Attitude and Involvement List-Short Form

   Measured using the Spiritual Attitude and Involvement List-Short Form (SAIL-SF; Bohlmeijer et al., 2023). The SAIL-SF measures seven dimensions of spiritual well-being: meaningfulness, trust, acceptance, caring for others, connectedness with nature, transcendent experiences, and spiritual activities. Each dimension is assessed by one item (e.g., "I experience the things I do as meaningful", "I try to take life as it comes"). Items are rated on a 6-point Likert scale ranging from 1 (not at all) to 6 (to a very high degree), with higher scores indicating greater spiritual well-being. The total score is calculated as the mean of all items.

   Time frame: Baseline

2. Spiritual well-being measured by Spiritual Attitude and Involvement List-Short Form

   Measured using the Spiritual Attitude and Involvement List-Short Form (SAIL-SF; Bohlmeijer et al., 2023). The SAIL-SF measures seven dimensions of spiritual well-being: meaningfulness, trust, acceptance, caring for others, connectedness with nature, transcendent experiences, and spiritual activities. Each dimension is assessed by one item (e.g., "I experience the things I do as meaningful", "I try to take life as it comes"). Items are rated on a 6-point Likert scale ranging from 1 (not at all) to 6 (to a very high degree), with higher scores indicating greater spiritual well-being. The total score is calculated as the mean of all items.

   Time frame: 1 month after baseline

3. Spiritual well-being measured by Spiritual Attitude and Involvement List-Short Form

   Measured using the Spiritual Attitude and Involvement List-Short Form (SAIL-SF; Bohlmeijer et al., 2023). The SAIL-SF measures seven dimensions of spiritual well-being: meaningfulness, trust, acceptance, caring for others, connectedness with nature, transcendent experiences, and spiritual activities. Each dimension is assessed by one item (e.g., "I experience the things I do as meaningful", "I try to take life as it comes"). Items are rated on a 6-point Likert scale ranging from 1 (not at all) to 6 (to a very high degree), with higher scores indicating greater spiritual well-being. The total score is calculated as the mean of all items.

   Time frame: 2 months after baseline

4. Spiritual well-being measured by Spiritual Attitude and Involvement List-Short Form

   Measured using the Spiritual Attitude and Involvement List-Short Form (SAIL-SF; Bohlmeijer et al., 2023). The SAIL-SF measures seven dimensions of spiritual well-being: meaningfulness, trust, acceptance, caring for others, connectedness with nature, transcendent experiences, and spiritual activities. Each dimension is assessed by one item (e.g., "I experience the things I do as meaningful", "I try to take life as it comes"). Items are rated on a 6-point Likert scale ranging from 1 (not at all) to 6 (to a very high degree), with higher scores indicating greater spiritual well-being. The total score is calculated as the mean of all items.

   Time frame: 4 months after baseline

Secondary outcomes

1. Grief intensity measured by Traumatic Grief Inventory-Self Report Plus

   Measured using the 22-item Traumatic Grief Inventory-Self Report Plus (TGI-SR+; Lenferink et al., 2022). Participants rated the extent to which they experienced each grief symptom during the past two weeks on 5-point Likert scale (1 = never to 5 = always). Total scores are calculated by summing all items (range: 22-110), with higher scores indicating greater grief intensity. A total score ≥71 indicates probable clinical DSM-5-TR PGD.

   Time frame: Baseline

2. Grief intensity measured by Traumatic Grief Inventory-Self Report Plus

   Measured using the 22-item Traumatic Grief Inventory-Self Report Plus (TGI-SR+; Lenferink et al., 2022). Participants rated the extent to which they experienced each grief symptom during the past two weeks on 5-point Likert scale (1 = never to 5 = always). Total scores are calculated by summing all items (range: 22-110), with higher scores indicating greater grief intensity. A total score ≥71 indicates probable clinical DSM-5-TR PGD.

   Time frame: 1 month after baseline

3. Grief intensity measured by Traumatic Grief Inventory-Self Report Plus

   Measured using the 22-item Traumatic Grief Inventory-Self Report Plus (TGI-SR+; Lenferink et al., 2022). Participants rated the extent to which they experienced each grief symptom during the past two weeks on 5-point Likert scale (1 = never to 5 = always). Total scores are calculated by summing all items (range: 22-110), with higher scores indicating greater grief intensity. A total score ≥71 indicates probable clinical DSM-5-TR PGD.

   Time frame: 2 months after baseline

4. Grief intensity measured by Traumatic Grief Inventory-Self Report Plus

   Measured using the 22-item Traumatic Grief Inventory-Self Report Plus (TGI-SR+; Lenferink et al., 2022). Participants rated the extent to which they experienced each grief symptom during the past two weeks on 5-point Likert scale (1 = never to 5 = always). Total scores are calculated by summing all items (range: 22-110), with higher scores indicating greater grief intensity. A total score ≥71 indicates probable clinical DSM-5-TR PGD.

   Time frame: 4 months after baseline

5. Nature connectedness measured by Inclusion of Nature in Self scale

   Measured using 1-item Inclusion of Nature in Self scale (INS; Schultz, 2001). The INS is a single-item pictorial measure that assesses the extent to which individuals include nature within their cognitive representation of self. The measure consists of seven pairs of circles labeled "self" and "nature" with varying degrees of overlap, from completely separate (1) to almost completely overlapping (7). Participants select the picture that best describes their relationship with the natural environment.

   Time frame: Baseline

6. Nature connectedness measured by Inclusion of Nature in Self scale

   Measured using 1-item Inclusion of Nature in Self scale (INS; Schultz, 2001). The INS is a single-item pictorial measure that assesses the extent to which individuals include nature within their cognitive representation of self. The measure consists of seven pairs of circles labeled "self" and "nature" with varying degrees of overlap, from completely separate (1) to almost completely overlapping (7). Participants select the picture that best describes their relationship with the natural environment.

   Time frame: 1 month after baseline

7. Nature connectedness measured by Inclusion of Nature in Self scale

   Measured using 1-item Inclusion of Nature in Self scale (INS; Schultz, 2001). The INS is a single-item pictorial measure that assesses the extent to which individuals include nature within their cognitive representation of self. The measure consists of seven pairs of circles labeled "self" and "nature" with varying degrees of overlap, from completely separate (1) to almost completely overlapping (7). Participants select the picture that best describes their relationship with the natural environment.

   Time frame: 2 months after baseline

8. Nature connectedness measured by Inclusion of Nature in Self scale

   Measured using 1-item Inclusion of Nature in Self scale (INS; Schultz, 2001). The INS is a single-item pictorial measure that assesses the extent to which individuals include nature within their cognitive representation of self. The measure consists of seven pairs of circles labeled "self" and "nature" with varying degrees of overlap, from completely separate (1) to almost completely overlapping (7). Participants select the picture that best describes their relationship with the natural environment.

   Time frame: 4 months after baseline

9. Nature connectedness measured by Connectedness to Nature Scale

   Measured using 14-item Connectedness to Nature Scale (CNS; Mayer \& Frantz, 2004). The CNS measures individuals' trait levels of feeling emotionally and experientially connected to the natural world. Participants rated items such as "I often feel a sense of oneness with the natural world around me" and "I think of the natural world as a community to which I belong" on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). The total score is calculated as the mean of all items after reverse-scoring items 4, 12, and 14, with higher scores indicating greater connectedness to nature.

   Time frame: Baseline

10. Nature connectedness measured by Connectedness to Nature Scale

    Measured using 14-item Connectedness to Nature Scale (CNS; Mayer \& Frantz, 2004). The CNS measures individuals' trait levels of feeling emotionally and experientially connected to the natural world. Participants rated items such as "I often feel a sense of oneness with the natural world around me" and "I think of the natural world as a community to which I belong" on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). The total score is calculated as the mean of all items after reverse-scoring items 4, 12, and 14, with higher scores indicating greater connectedness to nature.

    Time frame: 1 month after baseline

11. Nature connectedness measured by Connectedness to Nature Scale

    Measured using 14-item Connectedness to Nature Scale (CNS; Mayer \& Frantz, 2004). The CNS measures individuals' trait levels of feeling emotionally and experientially connected to the natural world. Participants rated items such as "I often feel a sense of oneness with the natural world around me" and "I think of the natural world as a community to which I belong" on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). The total score is calculated as the mean of all items after reverse-scoring items 4, 12, and 14, with higher scores indicating greater connectedness to nature.

    Time frame: 2 months after baseline

12. Nature connectedness measured by Connectedness to Nature Scale

    Measured using 14-item Connectedness to Nature Scale (CNS; Mayer \& Frantz, 2004). The CNS measures individuals' trait levels of feeling emotionally and experientially connected to the natural world. Participants rated items such as "I often feel a sense of oneness with the natural world around me" and "I think of the natural world as a community to which I belong" on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). The total score is calculated as the mean of all items after reverse-scoring items 4, 12, and 14, with higher scores indicating greater connectedness to nature.

    Time frame: 4 months after baseline

13. Mental well-being measured by Mental Health Continuum-Short Form

    Measured using the Mental Health Continuum-Short Form (MHC-SF; Lamers et al., 2011), a 14-item scale measuring three dimensions of well-being: emotional (3 items), psychological (6 items), and social well-being (5 items). Participants rated the frequency of experiencing various feelings of well-being during the past month on a 6-point Likert scale (0 = never to 5 = every day). Scores are calculated as the mean of all items, with higher scores indicating greater well-being.

    Time frame: Baseline

14. Mental well-being measured by Mental Health Continuum-Short Form

    Measured using the Mental Health Continuum-Short Form (MHC-SF; Lamers et al., 2011), a 14-item scale measuring three dimensions of well-being: emotional (3 items), psychological (6 items), and social well-being (5 items). Participants rated the frequency of experiencing various feelings of well-being during the past month on a 6-point Likert scale (0 = never to 5 = every day). Scores are calculated as the mean of all items, with higher scores indicating greater well-being.

    Time frame: 1 month after baseline

15. Mental well-being measured by Mental Health Continuum-Short Form

    Measured using the Mental Health Continuum-Short Form (MHC-SF; Lamers et al., 2011), a 14-item scale measuring three dimensions of well-being: emotional (3 items), psychological (6 items), and social well-being (5 items). Participants rated the frequency of experiencing various feelings of well-being during the past month on a 6-point Likert scale (0 = never to 5 = every day). Scores are calculated as the mean of all items, with higher scores indicating greater well-being.

    Time frame: 2 months after baseline

16. Mental well-being measured by Mental Health Continuum-Short Form

    Measured using the Mental Health Continuum-Short Form (MHC-SF; Lamers et al., 2011), a 14-item scale measuring three dimensions of well-being: emotional (3 items), psychological (6 items), and social well-being (5 items). Participants rated the frequency of experiencing various feelings of well-being during the past month on a 6-point Likert scale (0 = never to 5 = every day). Scores are calculated as the mean of all items, with higher scores indicating greater well-being.

    Time frame: 4 months after baseline

17. Selflessness measured by Perceived Body Boundaries Scale

    Perceived Body Boundaries Scale (PBBS; Dambrun, 2016). This scale comprises a single item designed to assess the strength of participants' perceived body boundaries. A series of images of human forms with increasingly transparent boundaries to indicate gradations of body boundary salience. "Which images best represent your perception of your body's boundaries right now?" Responses range from 1 (no boundary dissolution) to 7 (a lot of boundary dissolution).

    Time frame: Baseline

18. Selflessness measured by Perceived Body Boundaries Scale

    Perceived Body Boundaries Scale (PBBS; Dambrun, 2016). This scale comprises a single item designed to assess the strength of participants' perceived body boundaries. A series of images of human forms with increasingly transparent boundaries to indicate gradations of body boundary salience. "Which images best represent your perception of your body's boundaries right now?" Responses range from 1 (no boundary dissolution) to 7 (a lot of boundary dissolution).

    Time frame: 1 month after baseline

19. Selflessness measured by Perceived Body Boundaries Scale

    Perceived Body Boundaries Scale (PBBS; Dambrun, 2016). This scale comprises a single item designed to assess the strength of participants' perceived body boundaries. A series of images of human forms with increasingly transparent boundaries to indicate gradations of body boundary salience. "Which images best represent your perception of your body's boundaries right now?" Responses range from 1 (no boundary dissolution) to 7 (a lot of boundary dissolution).

    Time frame: 2 months after baseline

20. Selflessness measured by Perceived Body Boundaries Scale

    Perceived Body Boundaries Scale (PBBS; Dambrun, 2016). This scale comprises a single item designed to assess the strength of participants' perceived body boundaries. A series of images of human forms with increasingly transparent boundaries to indicate gradations of body boundary salience. "Which images best represent your perception of your body's boundaries right now?" Responses range from 1 (no boundary dissolution) to 7 (a lot of boundary dissolution).

    Time frame: 4 months after baseline

21. Selflessness measured by Spatial Frame of Reference Continuum

    Spatial Frame of Reference Continuum (SFoRC; Hanley \& Garland, 2019). This scale comprises a single item used to assess the extent to which the field of awareness is perceived to extend beyond the physical body. How far does your self extend into the world? Using the letters and image below, please indicate how far you feel that your self extends beyond your physical body. "A" represents your self stopping at your physical body. "F" represents your self extending into everything (e.g., the entire Universe). The letters inbetween "A" and "F" represent different levels of self-extension. The rings are symbolic, and do not represent actual distances.

    Time frame: Baseline

22. Selflessness (Spatial Frame of Reference Continuum)

    Spatial Frame of Reference Continuum (SFoRC; Hanley \& Garland, 2019). This scale comprises a single item used to assess the extent to which the field of awareness is perceived to extend beyond the physical body. How far does your self extend into the world? Using the letters and image below, please indicate how far you feel that your self extends beyond your physical body. "A" represents your self stopping at your physical body. "F" represents your self extending into everything (e.g., the entire Universe). The letters inbetween "A" and "F" represent different levels of self-extension. The rings are symbolic, and do not represent actual distances.

    Time frame: 1 month after baseline

23. Selflessness measured by Spatial Frame of Reference Continuum

    Spatial Frame of Reference Continuum (SFoRC; Hanley \& Garland, 2019). This scale comprises a single item used to assess the extent to which the field of awareness is perceived to extend beyond the physical body. How far does your self extend into the world? Using the letters and image below, please indicate how far you feel that your self extends beyond your physical body. "A" represents your self stopping at your physical body. "F" represents your self extending into everything (e.g., the entire Universe). The letters inbetween "A" and "F" represent different levels of self-extension. The rings are symbolic, and do not represent actual distances.

    Time frame: 2 months after baseline

24. Selflessness measured by Spatial Frame of Reference Continuum

    Spatial Frame of Reference Continuum (SFoRC; Hanley \& Garland, 2019). This scale comprises a single item used to assess the extent to which the field of awareness is perceived to extend beyond the physical body. How far does your self extend into the world? Using the letters and image below, please indicate how far you feel that your self extends beyond your physical body. "A" represents your self stopping at your physical body. "F" represents your self extending into everything (e.g., the entire Universe). The letters inbetween "A" and "F" represent different levels of self-extension. The rings are symbolic, and do not represent actual distances.

    Time frame: 4 months after baseline

25. Elevation measured by Elevating Experiences Scale

    Measured using the Elevating Experiences Scale (EES; Huta \& Ryan, 2010), a 13-item measure that captures feelings of transcendence, moral inspiration, and connection to something greater than oneself. Participants rated their experiences over the past two weeks using a 7-point Likert-type scale ranging from 1 (not at all) to 7 (extremely). Scores are calculated as the mean of all items, with higher scores indicating greater elevation.

    Time frame: Baseline

26. Elevation measured by Elevating Experiences Scale

    Measured using the Elevating Experiences Scale (EES; Huta \& Ryan, 2010), a 13-item measure that captures feelings of transcendence, moral inspiration, and connection to something greater than oneself. Participants rated their experiences over the past two weeks using a 7-point Likert-type scale ranging from 1 (not at all) to 7 (extremely). Scores are calculated as the mean of all items, with higher scores indicating greater elevation.

    Time frame: 1 month after baseline

27. Elevation measured by Elevating Experiences Scale

    Measured using the Elevating Experiences Scale (EES; Huta \& Ryan, 2010), a 13-item measure that captures feelings of transcendence, moral inspiration, and connection to something greater than oneself. Participants rated their experiences over the past two weeks using a 7-point Likert-type scale ranging from 1 (not at all) to 7 (extremely). Scores are calculated as the mean of all items, with higher scores indicating greater elevation.

    Time frame: 2 months after baseline

28. Elevation measured by Elevating Experiences Scale

    Measured using the Elevating Experiences Scale (EES; Huta \& Ryan, 2010), a 13-item measure that captures feelings of transcendence, moral inspiration, and connection to something greater than oneself. Participants rated their experiences over the past two weeks using a 7-point Likert-type scale ranging from 1 (not at all) to 7 (extremely). Scores are calculated as the mean of all items, with higher scores indicating greater elevation.

    Time frame: 4 months after baseline

29. Ability to adapt measured by Generic Sense of Ability to Adapt Scale

    Measured using the Generic Sense of Ability to Adapt Scale (GSAAS; Franken et al., 2023). The GSAAS is a 10-item scale measuring perceived ability to readjust and actively deal with the psychosocial consequences of challenging events. Items (e.g., "If something unexpected happens, I can easily adapt") are rated on a 5-point Likert scale from "not at all" (0) to "always" (4). The total score is calculated as the mean of all items, with higher scores indicating greater ability to adapt.

    Time frame: Baseline

30. Ability to adapt measured by Generic Sense of Ability to Adapt Scale

    Measured using the Generic Sense of Ability to Adapt Scale (GSAAS; Franken et al., 2023). The GSAAS is a 10-item scale measuring perceived ability to readjust and actively deal with the psychosocial consequences of challenging events. Items (e.g., "If something unexpected happens, I can easily adapt") are rated on a 5-point Likert scale from "not at all" (0) to "always" (4). The total score is calculated as the mean of all items, with higher scores indicating greater ability to adapt.

    Time frame: 1 month after baseline

31. Ability to adapt measured by Generic Sense of Ability to Adapt Scale

    Measured using the Generic Sense of Ability to Adapt Scale (GSAAS; Franken et al., 2023). The GSAAS is a 10-item scale measuring perceived ability to readjust and actively deal with the psychosocial consequences of challenging events. Items (e.g., "If something unexpected happens, I can easily adapt") are rated on a 5-point Likert scale from "not at all" (0) to "always" (4). The total score is calculated as the mean of all items, with higher scores indicating greater ability to adapt.

    Time frame: 2 months after baseline

32. Ability to adapt measured by Generic Sense of Ability to Adapt Scale

    Measured using the Generic Sense of Ability to Adapt Scale (GSAAS; Franken et al., 2023). The GSAAS is a 10-item scale measuring perceived ability to readjust and actively deal with the psychosocial consequences of challenging events. Items (e.g., "If something unexpected happens, I can easily adapt") are rated on a 5-point Likert scale from "not at all" (0) to "always" (4). The total score is calculated as the mean of all items, with higher scores indicating greater ability to adapt.

    Time frame: 4 months after baseline

33. Personal recovery measured by Brief INSPIRE-O

    Measured using the 5-item Brief INSPIRE-O, modified from the Brief INSPIRE support measure (Williams et al., 2015). Items are rated on a 5-point Likert scale from 0 (not at all) to 4 (very much). Following scoring guidelines (Moeller et al., 2023), raw scores were summed and multiplied by 5 to give a total score ranging from 0 to 100, with higher scores indicating better personal functioning.

    Time frame: Baseline

34. Personal recovery measured by Brief INSPIRE-O

    Measured using the 5-item Brief INSPIRE-O, modified from the Brief INSPIRE support measure (Williams et al., 2015). Items are rated on a 5-point Likert scale from 0 (not at all) to 4 (very much). Following scoring guidelines (Moeller et al., 2023), raw scores were summed and multiplied by 5 to give a total score ranging from 0 to 100, with higher scores indicating better personal functioning.

    Time frame: 1 month after baseline

35. Personal recovery measured by Brief INSPIRE-O

    Measured using the 5-item Brief INSPIRE-O, modified from the Brief INSPIRE support measure (Williams et al., 2015). Items are rated on a 5-point Likert scale from 0 (not at all) to 4 (very much). Following scoring guidelines (Moeller et al., 2023), raw scores were summed and multiplied by 5 to give a total score ranging from 0 to 100, with higher scores indicating better personal functioning.

    Time frame: 2 months after baseline

36. Personal recovery measured by Brief INSPIRE-O

    Measured using the 5-item Brief INSPIRE-O, modified from the Brief INSPIRE support measure (Williams et al., 2015). Items are rated on a 5-point Likert scale from 0 (not at all) to 4 (very much). Following scoring guidelines (Moeller et al., 2023), raw scores were summed and multiplied by 5 to give a total score ranging from 0 to 100, with higher scores indicating better personal functioning.

    Time frame: 4 months after baseline

37. Daily diary (assessed daily during 14-day intervention period)

    "Please respond to the following items based on your experiences and feelings today, reflecting specifically on the past 24 hours." Responses range from 1 (not at all) to 7 (very much). 1. Grief reactions (2 items) 2. Positive affect (2 items) 3. Negative affect (2 items) 4. Nature connectedness (1 item; Schultz, 2001) 5. Selflessness (1 item; Dambrun, 2016) 6. Spiritual well-being (1 item; Underwood, 2011) 7. Ability to adapt (1 item; Franken et al., 2023) * Analysis metric: Daily fluctuations and sudden gains

    Time frame: From baseline to post-intervention (2-weeks)

Other outcomes

1. Demographic characteristics

   Age, gender, education level, employment status

   Time frame: Baseline

2. Loss-related characteristics

   (1) Relationship to the deceased (categorized as spouse/partner, child, parent, sibling, other family member, or friend); (2) Time since loss (measured in months since death occurred); and (3) Cause of death (categorized as natural anticipated, natural sudden, accident, suicide, homicide, or other/unknown). These variables will be reported using descriptive statistics, with categorical variables presented as frequencies and percentages, and continuous variables (time since loss) presented as means and standard deviations.

   Time frame: Baseline

3. Previous mindfulness experience

   Using two complementary items. First, participants will respond to the question "Do you have experience with meditation?" with three response options: "Yes, I would call myself an expert and have a lot of experience with meditation," "Yes, I have a little experience with meditation," or "No, I have no experience with meditation (yet)." Second, current practice frequency will be assessed with the question "How many times have you meditated in the past month?" with four response options: "Daily," "Weekly," "Occasionally," or "Never."

   Time frame: Baseline

4. Previous Nature experience

   Participants will respond to the question "Are you regularly in nature (such as the forest, a park or the beach)?" with five response options: "Yes, every day," "Yes, one or more times a week," "Yes, once a month," "No, rarely," or "No, never."

   Time frame: Baseline

5. Intervention adherence

   A post-intervention adherence item measuring self-reported frequency of practice completion and duration of practice sessions. Adherence will be operationalized as the percentage of assigned sessions completed (ranging from 0-100%) and reported as means, standard deviations, and frequency distributions.

   Time frame: 1 month after baseline

6. Co-intervention use

   Participants will respond to the question: "During the past 2 weeks, did you receive additional psychological professional support from a psychologist, therapist, or psychiatrist for dealing with your emotional problems?" Results will be reported as frequencies and percentages. Co-intervention use will be examined as a potential confounding variable in the analysis to determine whether concurrent psychological support interacts with the intervention effects.

   Time frame: 1 month after baseline

7. Client satisfaction measured by Client Satisfaction Questionnaire

   Measured using 8-item Client Satisfaction Questionnaire (CSQ-8; Attkisson \& Zwick, 1982). Items will be scored on a 4-point scale, and a sum score (8-32) will be calculated with higher scores being indicative of a larger satisfaction with the intervention.

   Time frame: 1 month after baseline

Individual participant data

Plan to share: Undecided