RESEARCH ARTICLE Open Access

The health impact of residential retreats: asystematic reviewDhevaksha Naidoo1, Adrian Schembri2 and Marc Cohen1*

Abstract

Background: Unhealthy lifestyles are a major factor in the development and exacerbation of many chronic diseases.Improving lifestyles though immersive residential experiences that promote healthy behaviours is a focus of the healthretreat industry. This systematic review aims to identify and explore published studies on the health, wellbeing andeconomic impact of retreat experiences.

Methods: MEDLINE, CINAHL and PsychINFO databases were searched for residential retreat studies in Englishpublished prior to February 2017. Studies were included if they were written in English, involved an intervention programin a residential setting of one or more nights, and included before-and-after data related to the health of participants.Studies that did not meet the above criteria or contained only descriptive data from interviews or case studies wereexcluded.

Results: A total of 23 studies including eight randomised controlled trials, six non-randomised controlled trials and ninelongitudinal cohort studies met the inclusion criteria. These studies included a total of 2592 participants from diversegeographical and demographic populations and a great heterogeneity of outcome measures, with seven studies examiningobjective outcomes such as blood pressure or biological makers of disease, and 16 studies examining subjective outcomesthat mostly involved self-reported questionnaires on psychological and spiritual measures. All studies reported post-retreathealth benefits ranging from immediately after to five-years post-retreat. Study populations varied widely and most studieshad small sample sizes, poorly described methodology and little follow-up data, and no studies reported onhealth economic outcomes or adverse effects, making it difficult to make definite conclusions about specificconditions, safety or return on investment.

Conclusions: Health retreat experiences appear to have health benefits that include benefits for people withchronic diseases such as multiple sclerosis, various cancers, HIV/AIDS, heart conditions and mental health. Future researchwith larger numbers of subjects and longer follow-up periods are needed to investigate the health impact of differentretreat experiences and the clinical populations most likely to benefit. Further studies are also needed to determine theeconomic benefits of retreat experiences for individuals, as well as for businesses, health insurers and policy makers.

Keywords: Wellbeing, Wellness tourism, Medical tourism, Lifestyle, Retreat experience, Multiple sclerosis, Cancer, Heartdisease, Mental health

BackgroundLifestyle-related chronic diseases such as obesity, dia-betes and lung disease are a global issue, which theWorld Health Organisation estimate account for 60% ofall deaths [1]. These diseases are characterised by modi-fiable risk factors such as physical inactivity, unhealthydiet such as diets high in salt, sugar, fat, alcohol and

tobacco, and exposure to environmental toxicants [1].Unhealthy lifestyles are a major factor in the develop-ment of chronic disease and are directly addressed bythe health retreat industry, which promises to deliver en-hanced health and the reversal of chronic disease andage-related conditions by engaging people directly inhealthy lifestyle behaviours and experiences [2–4].Health retreats have emerged from a history of travel

to foreign destinations such as spas, hot springs, sacredsites, and pilgrimage locations that have been used as

* Correspondence: marc.cohen@rmit.edu.au1School of Health and Biomedical Sciences, RMIT University, Plenty Rd,Bundoora, Bundoora, VIC 3083, AustraliaFull list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 DOI 10.1186/s12906-017-2078-4

places of rest and rejuvenation for countless generations[3, 5]. Such locations have given rise to a booming well-ness tourism industry that is estimated to have generatedUS$563.2 billion in revenues in 2015, with growth pro-jections that are nearly 50% faster than for overall globaltourism [6, 7]. A retreat may be defined as “a purpose-built centre which accommodates its guests for the pur-pose of learning/improving a body-mind activity (e.g.,yoga, pilates) and/or learning-receiving complementarytherapies or treatments whilst there” [2]. Retreats covera broad spectrum of facilities ranging from low-cost ash-rams in India [2, 3, 8] that focus on a spiritual-based life-style, to luxury lifestyle resorts [8], to residential centersthat focus on chronic disease. Retreat guests range frompeople who want to improve their general health andlearn positive lifestyle practices, to those facing life-threatening illnesses, and others who seek greater spirit-ual awareness or body-mind-spirit rejuvenation [9].Despite the growing popularity of retreats and the

growth of wellness tourism, the health impacts (eitherpositive or negative) of attending retreats are uncertainand it is unclear if retreats offer any economic return forindividuals or other stakeholders such as businesses,health insurance companies or governments. This paperaims to systematically review published studies that re-port on the health, wellbeing and economic impact ofretreat experiences according to the PICOS approach(Participants, Intervention, Comparators, Outcomes andStudy design) [10], and thereby explore the impact ofthese experiences on retreat guests.

MethodsSearch strategy and data sourcesA literature search was conducted in February 2017using the electronic databases MEDLINE, CINAHL, andPsychINFO using search terms as appropriate for eachof the databases. The search used combinations of key-words and phrases (retreat, health, wellness, wellbeing,resident) to conduct the systematic review. Truncationof keywords was used where variations of these wordsmay alter search results. In addition reference lists of allrelevant studies were manually searched.

Inclusion/ exclusion criteriaStudies were included if they were published prior toFebruary 2017, written in English, and contained beforeand after data related to health and wellbeing of retreatguests. As there is no strict definition of ‘retreat’, we in-cluded all studies that had at least one health-relatedoutcome and the intervention involved a residential set-ting of one or more nights. Studies that did not meet theabove criteria or contained only descriptive data frominterviews or case studies were excluded. We did not ex-clude studies based on the purpose of the retreat.

Data extractionEach potentially eligible study identified in the literaturesearch was independently screened according to the studyinclusion criteria and then independently reviewed.Detailed summary tables of the studies were prepared ac-cording to the PICOS approach [10]. Participants includedboth healthy people and people with specific diseases whoattended the relevant retreat program; the interventionswere all residential retreat programs that involved one ormore nights stay excluding hospital stays; comparisonswere made between post-retreat and pre-retreat measures;and outcomes included any physiological, psychological,or other clinically relevant outcomes. Data from all in-cluded studies were extracted by two independent authorsand presented in Tables 1, 2 and 3 along with p valueswhen p was less than 0.05.

Risk of bias assessmentTwo review authors independently assessed the risk of biasof each included Randomised Controlled Trial study usingthe Cochrane Risk of Bias tool including key criteria suchas random sequence generation, allocation concealment,blinding of participants, blinding of personnel and out-comes, incomplete outcome data, selective outcomereporting, and other sources of bias in accordance withmethods recommended by The Cochrane Collaboration[11]. The following judgements were used; low risk, highrisk or unclear (either lack of information or uncertaintyover poteintial for bias). Non-Randomised ControlledStudies and Longitudinal Cohort Studies were assessedusing the Risk of Bias in Non-Randomised Studies-of In-terventions (ROBINS-I) tool. Key criteria included con-founding, participant selection, intervention classification,deviations from intended interventions, missing data, out-comes measurement and reported results. The followingjudgements were used; low risk, moderate risk, serious risk,critical risk or no information. Authors resolved disagree-ments by consensus, and a third author was available forconsultation to resolve any discrepancies if necessary. Riskof bias assessments are summarised in Tables 4, 5 and 6.

ResultsThere were 23 studies (reported in 28 articles) included inthis systematic review, published over a 22-year periodfrom 1995 to 2017 and involving 2592 participants. Of the23 studies included, eight were randomised controlled tri-als (RCTs) including, one quasi-randomised trial and onerandomised multi-centre trial; six non-randomised con-trolled trails and nine longitudinal cohort studies. A studyflow chart is provided in Fig. 1. The results from the RCTsare presented in Table 1, results from the non-randomisedcontrolled trials are presented in Table 2 and results fromthe longitudinal cohort studies are presented in Table 3.

Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 Page 2 of 17

Table

1Summaryof

Rand

omised

Con

trolledTrialsof

RetreatInterven

tions

Reference

Stud

yde

sign

Popu

latio

n(includ

escomparatorgrou

p/s)

Interven

tion

Place(boldfont

indicatescoun

try)

Com

parator

Timingof

measures

OutcomeMeasures

Results

Epelet

al.,

2016

[1]

RCT

Health

ywom

en(n=94);Expe

rienced

med

itator(n=30),

Novicemed

itator

(n=33),Vacatio

n(n=31)

5-dayMed

itatio

nRetreat:

Med

itatonandyoga.

Cho

praCen

terfor

Wellbeing

,LaCosta

Resort,C

arlsbad,

California,U

nited

States

Vacatio

nat

the

samevenu

ewith

out

med

itatio

nretreatactivities

Pre-retreat,po

st-

retreat,1and10

mon

thspo

st-retreat.

Gen

eexpression

change

s(transcriptome-

wideexpression

patterns),

aging-relatedbiom

arkers

(telom

eraseactivity,A

βpe

ptidelevels),de

pressive

symptom

s,pe

rceived

stress,vitalityand

mindfulne

ss.

Highlysig.

Gen

eexpression

change

sob

served

across

all

grou

pspo

st-retreat

(the

‘vacationeffect’)

characterized

byim

proved

regu

latio

nof

stress

respon

se,immun

efunctio

nandam

yloid

beta

(Aβ)

metabolism.

Sig.im

provem

entin

all

grou

psin

depressive

symptom

s,pe

rceived

stress,m

indful

awaren

ess

andvitalityim

med

iately

afterand1-mon

thpo

st-retreat.The

novice

grou

pim

proved

sig

moreon

mindfulne

ssthan

theothe

rtw

ogrou

psat

day5andat

1-mon

thand10-m

onths

post-retreat.

Millset

al.,

2016

[2]

Quasi-

rand

omised

trial

Health

ymen

and

wom

en(n=119);I

ntervention(n=65),

Vacatio

n((n

=54)

6-dayPanchakarm

aAyurved

icRetreat‘Perfect

Health

(PH)P

rogram

’:Ph

ysicalcleansing

throug

hinge

stionof

herbs,fib

er,and

oils.

Twice-daily

Ayurved

iclight

plant-basedmeals.

DailyAyurved

icoil

massage

,heatin

gtreatm

ents(sauna

and/or

steam,lectureson

Ayurved

icprinciples,

lifestyle,m

editatio

nand

yoga

philosoph

y.Tw

ice-daily

grou

pmed

itatio

n,daily

yoga

andbreathingexercises

(pranayama),emotional

expression

throug

hjournalingandem

otional

supp

ort.Integrative

med

icalconsultatio

n(1-h)

with

aph

ysicianand

follow-upwith

Ayurved

iche

alth

educator.

Cho

praCen

terfor

Wellbeing

,LaCosta

Resort,C

arlsbad,

California,U

nited

States

Vacatio

nat

the

samevenu

ewith

out

med

itatio

nretreatactivities

Pre-retreat,po

st-

retreatand1and

10mon

ths

post-retreat.

TheSpirituality

Scale,

Gratitud

equ

estio

nnaire,

Self-Com

passionScale,

RyffScaleof

Psycho

logical

Wellbeing

,Cen

terfor

Epidem

iology

Stud

ies-

Dep

ression(CES-D)tool,

Patient-Rep

orted

Outcomes

Measuremen

tSystem

(PRO

MIS)A

nxiety

Scale.Otheroutcom

esobtained

wereBP,heigh

t,weigh

t(reported

inPeterson

2016)

Sig.increasesin

spirituality

(p<0.01)and

gratitu

de(p<0.05)in

the

retreatgrou

pandno

change

incontrolg

roup

.Sustaine

dincreasesin

spirituality

(p<0.01),

gratitu

de.and

self-

compassion(p<0.01)

andredu

cedanxiety

(p<0.05)at

1-mon

thfollow-up.

Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 Page 3 of 17

Table

1Summaryof

Rand

omised

Con

trolledTrialsof

RetreatInterven

tions

(Con

tinued)

Reference

Stud

yde

sign

Popu

latio

n(includ

escomparatorgrou

p/s)

Interven

tion

Place(boldfont

indicatescoun

try)

Com

parator

Timingof

measures

OutcomeMeasures

Results

Peterson

etal.,2016

[3]

RCT

Health

ymen

and

wom

en(n=119);

Interven

tion(n=65),

Vacatio

n(n=54)

6-dayPanchakarm

aAyurved

icRetreat‘Perfect

Health

(PH)P

rogram

’:Ayurved

iche

rbsusing

theZriipu

rifyhe

rbal

prog

ram,veg

etariandiet,

med

itatio

n,yoga,

Ayurved

icoilm

assage

,he

attherapiesand

lectures

onself-care

and

wellbeing

.

Cho

praCen

trefor

Wellbeing

,LaCosta

Resort,C

arlsbad,

California,U

nited

States

Vacatio

nat

the

samevenu

ewith

out

med

itatio

nretreatactivities

Preandpo

st-retreat

BMI,systolicanddiastolic

BP,heartrate,saliva,stoo

l,fastingbloo

dsample,

alcoho

luse,caffeineuse,

biolog

icalmarkersof

cell

biolog

y,ge

nome,

metabolom

eand

microbiom

e.Psycho

logical

indicesof

wellbeing

(reported

inMills2016)

Statisticallysig.

Chang

es(decrease)

inplasmalevelsof

phosph

atidylcholines,

sphing

omyelinsand

othe

rsafter6days.

Tarenet

al.,

2015

[4]

Sing

le-blind

RCT

Stressed

unem

ployed

job-seekingcommun

ityadults((n

=35);Inter

vention(n=18),Vac

ation(n=17)

3-dayEnhancem

ent

Throug

hMindfulne

ss(HEM

)Retreat:

Mindfulne

sstraining

throug

hbo

dyscan

awaren

essexercises,

sittingandwalking

med

itatio

ns,m

indful

eatin

gandmindful

movem

ent(gen

tlehatha

yoga

postures),discussion

ofindividu

alob

servations

andpractices.

Reside

ntialR

etreat,

Pittbu

rgh,

Penn

sylvania,U

nited

States

Vacatio

nat

the

samevenu

ewith

out

med

itatio

nretreatactivities

Pre-retreat(upto

4weeks

before),

post-retreat

(upto

2weeks

after)and

4 mon

thspo

st-

retreat

Neuroim

agingassessmen

t(re

stingstatefunctio

nal

conn

ectivity

(rsFC

)scan),

hairsample(cum

ulative

hypo

thalam

ic-pitu

itary-

adrenal(HPA

)axis

activation),Perceived

Stress

Scale(PSS).

Sig.change

sin

resting

statefunctionalconnectivity

(rsFC)intheright

amygdala-subgenual

anteriorcingulate

cortex(sgA

CC)of

interventiongroup

(time-treatment

interactionp<0.05).

Gilbertet

al.,

2014

[5]

RCT

Wom

en,age

d31

to60,w

ithno

med

itatio

nexpe

rience

(n=66)rand

omised

tointerven

tionor

vacatio

n((n

=no

trepo

rted

)control

(n=no

trepo

rted

)

5-dayresortstay

toattend

med

itatio

n,yoga,

awaren

essandself-

reflectiontraining

(interven

tion)

orto

relax

attheresortandreceive

health

lectures

(con

trol).

Both

grou

psreceived

the

samediet.

Cho

praCen

terfor

Wellbeing

,LaCosta

Resort,C

arlsbad,

California,U

nited

States

Vacatio

nat

the

samevenu

ewith

out

med

itatio

nretreatactivities

Pre-

andpo

st-

retreat

Stress,affect,reactivity

andrumination(end

-of

daydiaries).

Sig.increase

inpo

sitive

affect

andde

crease

inne

gativeaffect

post-

retreatin

theretreatbu

tno

tthecontrolg

roup

.Bo

thgrou

psfeltless

‘stressed

’post-retreat

(p’s<.001).O

nlyretreat

wom

enrepo

rted

sig.

Greater

controlo

ver

stressors(p=.01).A

llparticipantsrepo

rted

decreasedrumination

post-retreat,w

ithmore

pron

ounced

change

sin

theretreatgrou

p(p’s<.001).

Pidg

eon

etal.,2014

[6]

RCT

Hum

anservices

profession

als(n=44);

Interven

tion(n=22),

Nilinterven

tion

((n=22)

2.5-dayMindfulne

sswith

Metta

Training

(MMTP)

Retreatand2×4-Hou

rFollow-upover

12-w

eeks:

Perio

dsof

silence,training

inmindfulne

ssandmetta

skillsandcogn

itive

Reside

ntialFacility,

Southe

rnQueen

sland,

Australia

No

interven

tion

Pre-retreat,po

st-

retreat,1and4

mon

thspo

st-retreat

Resilience(The

Resilience

Scale),M

indfulne

ss(The

Five

FacetMindfulne

ssQuestionn

aire)and

Self-compassion(The

Self-Com

passionScale).

Nosig.

Differen

ces

repo

rted

immed

iately

post-retreat

with

sig.

Improvem

entsin

mindfulne

ssandself-

compassionin

theretreat

grou

pat

1-and4-

Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 Page 4 of 17

Table

1Summaryof

Rand

omised

Con

trolledTrialsof

RetreatInterven

tions

(Con

tinued)

Reference

Stud

yde

sign

Popu

latio

n(includ

escomparatorgrou

p/s)

Interven

tion

Place(boldfont

indicatescoun

try)

Com

parator

Timingof

measures

OutcomeMeasures

Results

therapystrategies

toincrease

mindfulne

ssand

self-compassion.Follow-

upinclud

edreview

and

practiceof

mindfulne

ss,

metta

andcogn

itive

strategies.

mon

thspo

st-retreat

and

inresilienceat

4-mon

ths

post-retreat.

Kwiatkow

ski

etal.,2013

[7]

Rand

omised

multicen

ter

trial

Non

-metastatic

breast

cancer

patientsin

completeremission

(n=232)

interven

tion

(n=117),con

trol

(n=115)

13-day

SPAstay

bysm

allg

roup

sof

patients

comprisingph

ysical

training

,dietary

education,ph

ysiotherapy

andSPAcares.

ThreeSPAcentres:

Vichy,Le-M

ont-Dore,

Chaˆtel-Guyon

,Fran

ce

Not

repo

rted

Pre-retreatand

every6mon

ths

post-retreat

for

next

3years

Anthrop

ometric

measures;

Qualityof

Life

(SF36

questio

nnaire),Anxiety

andDep

ression(Hospital

Anxiety

andDep

ression

(HAD)qu

estio

nnaire)

Sig.increase

inSF36

scoreby

9.5po

ints

(p<0.001),4.6(p<0.5)

and6.2(p<0.05)

respectivelyat

6,12

and

24mon

ths.Anxiety

and

depression

scorewere

redu

cedat

6,12

and24

mon

ths.

Brazieret

al.,

2006

[8]

RCT

HIV/AIDSpatients

(n=47);Interven

tion

(n=20),Standard

care

(n=27)

15-day

Art-of-Livingwith

HIV

RetreatandWeekly

Follow-upfor12

weeks:

Breathingtechniqu

es,

med

itatio

n,movem

ent

andgrou

pprocess.Three

breathingexercisesare

theessentialelemen

tsof

theprog

ram,p

articularly

theSudarshanKriyaor

HealingBreath.A

tthe

endof

theretreat,

participantsweregivena

daily

homepractice.

Follow-upsessions

includ

edreview

ing

proced

ures

from

retreat.

Reside

ntialA

OL

facilityin

Quebe

c,standard

care

and

follow-upin

Vancou

ver,Can

ada

Standard

care

Pre-retreatand1,6

and12

weeks

post

retreat

Gen

eralwell-b

eing

,Men

tal

Health

Inde

x(M

HI),Health

-relatedqu

ality

oflife(M

OS-

HIV

Survey),Stress

(Daily

Stress

Inventory(DSI)).

Sig.po

sitivechange

sin

wellbeing

,post-retreat

with

nochange

atlater

timepo

ints.

Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 Page 5 of 17

Table

2Summaryof

Non

-Rando

mised

Con

trolledTrialsof

RetreatInterven

tions

Reference

Stud

yde

sign

Popu

latio

n(includ

escomparatorgrou

p/s)

Interven

tion

Place(boldfont

indicatescoun

try)

Com

parator

Timingof

measures

OutcomeMeasures

Results

Al-H

ussaini

etal.,2001

[9]

Observatio

nal

stud

ywith

control

VipassanaMed

itatio

nCou

rseparticipants

(n=45);Interven

tion

(n=14),Nil

Interven

tion(n=31)

10-day

Vipassana

Med

itatio

nretreat

involvingsilent

sitting

and/or

walking

med

itatio

n,avoidance

ofcaffeineand

alcoho

l,specific

breathingpractices

anddaily

lectures.

Muscat,Oman

Nointerven

tion

Preandpo

st-

retreat

Gen

eralHealth

(Gen

eral

Health

Questionn

aire

(GHQ-28))

Sig.

improvem

ents

inph

ysicaland

psycho

logical

well-b

eing

inthe

Vipassanabu

tno

tcontrolg

roup

.

Khurana&

Dhar,2000

[10]

Observatio

nal

stud

ywith

controls

MaleandFemale

Prison

inmates

(n=150);Intervention

(n=75),Nil

Interven

tion(n=75).

10-day

Vipassana

Med

itatio

nretreat

involvingsilent

sitting

and/or

walking

med

itatio

n,avoidance

ofcaffeineand

alcoho

l,specific

breathingpractices

anddaily

lectures.

TiharJail,India

Nointerven

tion

Preandpo

st-

retreat

SubjectiveWell-b

eing

,scale),Q

ualityof

Life

(Life

SatisfactionScale),

Crim

inalProp

ensity

Scale.

Sig.

improvem

entsin

Crim

inalProp

ensity

and

SubjectiveWell-b

eing

inmaleinmates

ofVipassanagrou

pcomparedwith

conrol.

Emavardh

ana

&Tori,1997

[11]

Observatio

nal

stud

ywith

controls

Teen

agers,some

teache

rsandothe

radults(n=719);

Interven

tion(n=438),

NilInterven

tion

(n=281)

7-dayVipassana

Med

itatio

nretreat

involvingsilent

sitting

and/or

walking

med

itatio

n,avoidance

ofcaffeineand

alcoho

l,specific

breathingpractices

anddaily

lectures.

Youn

gBu

ddhists

AssociationRetreat

Center,Bangkok,

Thailand

Nointerven

tion

Preandpo

st-

retreat

SelfEsteem

(Ten

nessee

Self-Co

nceptScale(TSCS)),

LifeStyleIndex,Budd

hist

BeliefsandPractices

Scale

Sig.

improvem

entin

self-esteem

andself-

concep

tpo

st-retreat

Chand

iramani

etal.,1995

[12]

Observatio

nal

stud

y(study

I)Observatio

nal

stud

ywith

control(stud

yII)

Prison

inmates

(n=270);Study

I(n=120),N

ocomparator.Stud

yII

(n=150),Intervention

(n=85),Nil

Interven

tion(n=65).

10-day

Vipassana

Med

itatio

nretreat

involvingsilent

sitting

and/or

walking

med

itatio

n,avoidance

ofcaffeineand

alcoho

l,specific

breathingpractices

anddaily

lectures.

TiharJail,India

Nointerven

tion

Pre-retreat,po

st-

retreat,3and

6mon

thspo

st-

retreat(study

IIon

ly)

Well-b

eing

(Psycholog

ical

Gen

eralWell-b

eing

Inde

x(PGI)scale),H

ope(M

iller

andPo

wer

hope

scale),

hostility

questio

nnaire

Sig.

improvem

entin

physicaland

psycho

logicalh

ealth

intheinterven

tiongrou

p(Study

II).Bothstud

ies

show

edsig.

Redu

ctions

inanxietyand

depression

scores

post-

retreat(p<0.001)

inthe

Vipassanagrou

pbu

tno

tin

thecontrolg

roup

.

Garland

etal.,

2009

[13];

Garland

,2007

[14];A

ngen

etal.,2002

[15]

Long

itudinal

coho

rtstud

ywith

control

Advancedbreast,

prostate

orcolon

cancer

patients

(n=15),theirpartne

rs(n=15),natural

historygrou

pof

patients(n=20)and

theirpartne

rs(n=20)

5-dayTape

stry

Psycho

socialRetreat:

Intensivepsycho

social

interven

tionfor

palliativecare

patients

andtheirpartne

rsbasedon

the

Com

mon

wealC

ancer

HelpProg

ram.

Retreatand

Rene

walCen

tre

outsideof

Calgary,

Can

ada

Nointerven

tion

Pre-retreat,po

st-

retreat,1,3,6,9,

and12

mon

ths

post-retreat

Qualityof

Life

(Fun

ctional

Assessm

entof

Cancer

Therapy–Gen

eralForm

(FACT-G),McG

illQuality

ofLife

Questionn

aire

(MQOL),Q

ualityof

Life

inLife

Thretreatin

gIllne

ss–

Family

(QOLLTI-F)

questio

nnaire,Fatigue

Patientsin

thetape

stry

grou

pde

mon

stratedSig.

improvem

entin

marital

satisfaction(p=.011)

with

less

psycho

logical

wellbeing

(p=0.029),

supp

ort(p=0.021)

and

poorer

socialwellbeing

(p=0.01)th

anpatientsin

Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 Page 6 of 17

Table

2Summaryof

Non

-Rando

mised

Con

trolledTrialsof

RetreatInterven

tions

(Con

tinued)

Reference

Stud

yde

sign

Popu

latio

n(includ

escomparatorgrou

p/s)

Interven

tion

Place(boldfont

indicatescoun

try)

Com

parator

Timingof

measures

OutcomeMeasures

Results

(Fun

ctionalA

ssessm

entof

CancerTherapy–Fatig

ue(FACT-F)),Spirituality

and

Purpose(Fun

ctional

Assessm

entof

Chron

icIlnessandTreatm

ent-

SpirtualitySubscale

FACIT-Sp))Dep

ression

(BeckDep

ression

Inventory-II,Hop

elessness

Scale,BriefS

ymptom

Inventory-18),Inde

xof

maritalsatisfaction(IM

S).

thenaturalh

istory

grou

p.Partne

rsof

patientsin

the

Tape

stry

grou

prepo

rted

morefinancialworriesp

=0.05,and

less

marital

satisfactionp=0.05

than

partne

rsof

patientsno

tattend

ingtheretreat.

Both

theTape

stry

and

naturalh

istory

grou

psrepo

rted

morefatig

ueas

timeprog

ressed

regardless

ofgrou

ps.

Ornishet

al.,

2013

[16];

Ornishet

al.,

2008

[17]

Descriptive

stud

ywith

control

Men

with

biop

sy-

proven

low-risk

prostate

cancer

(n=35);Interven

tion

(n=10),Standard

care

(n=25)

3-dayLifestyle

Mod

ificatio

nRetreat

andOutpatient

phase

aspartof

3-mon

thCom

preh

ensive

LifestyleMod

ificatio

nProg

ram:Low

-fat,

who

lefood

s,plant-

baseddiet

with

supp

lemen

ts.Stress

managem

ent(gen

tleyoga-based

stretching

,breathing

,med

itatio

n,im

agery,

andprog

ressive

relaxatio

n),m

oderate

aerobicexercise

and

weeklygrou

psupp

ort

sessions.Edu

catio

nandcoun

selling

byregistered

dietitian,

exercise

physiologist,

clinicalpsycho

logist,

nurse,andstress

managem

ent

instructor.O

utpatient

phaseinclud

edweeklyteleph

one

contactwith

astud

ynu

rse.

Retreatlocatio

nno

trepo

rted

,UnitedStates

Standard

care

Pre-retreat,po

st-

retreatand5years

post-retreat

BMI,bloo

dpressure,

relativetelomereleng

thof

perip

heralb

lood

mon

onuclear

cells

and

telomeraseactivity,

Lifestyleadhe

rence

(Lifestyle-inde

xscores).

Sig.

improvem

entsin

weigh

t,abdo

minal

obesity,b

lood

pressure,

andlipid

profile

were

observed

(allP<0.05).

Sig.

increase

inrelative

telomereleng

thafter

5yearsin

retreatgrou

pcomparedto

decrease

incontrol.Adh

eren

ceto

lifestylechange

sassociated

with

sig.

Increase

intelomere

leng

thcomparedwith

control.

Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 Page 7 of 17

Table

3Summaryof

Long

itudinalC

ohortStud

iesof

RetreatInterven

tions

Reference

Stud

yde

sign

Popu

latio

n(includ

escomparatorgrou

p/s)

Interven

tion

Place(boldfont

indicatescoun

try)

Timingof

measures

OutcomeMeasures

Results

New

berg

etal.,

2017

[18]

Observatio

nal

stud

yChristianfaith

(n=14),

Nocomparator

7-dayIgnatianSpiritual

Retreat:Morning

mass,

person

alreflection,

contem

plation,prayer,d

aily

meetin

gwith

Spiritual

Director.M

ealseatenin

common

dining

area

with

othe

rretreatantsbu

ttypically

maintainoverallsilenceof

theretreat.

JesuitCen

ter,

Werne

rsville,

Penn

sylvania,

UnitedStates

Pre-retreat(upto

1mon

thbe

fore)

andpo

st-retreat

(up

to2weeks

after)

Dop

amineandseratonin

transporterbind

ingin

midbrain(DaTscan

sing

leph

oton

emission

compu

tedtomog

raph

y(SPECT

)),Speilberge

rState

TraitAnxiety

Inventory

(STA

I-Y),Profile

ofMoo

dsScale(POMS),Beck

Dep

ressionInventory

(BDI),ShortForm

Health

Survey

(SF-12),Cloning

erSelfTranscen

denceScale,

Spirituality

(Inde

xof

Core

SpiritualExpe

riences

(INSPIRIT))

Sig.

decreasesin

dopaminetransporter

bind

ingin

thebasal

gang

liaandin

serotonin

transporterbind

ingin

the

midbrainpo

st-retreat.Sig.

change

sin

avariety

ofpsycho

logicaland

spiritualmeasures

includ

ingim

provem

ent

inpe

rceivedph

ysical

health,d

ecreases

intensionandfatig

ue,m

ore

intensereligious

and

spiritualbe

liefs,feeling

morereligious

andmore

spiritualandincrease

infeelings

ofself-

transcen

dence.

Coh

enet

al.,

2017

[19]

Observatio

nal

stud

yGwingann

aLifestyle

retreatgu

ests(n=37),

Nocomparator

7-dayGwingann

aLifestyle

Retreat:Cho

iceof

nature

walks,b

oxing,

dance,spin

classes,qi

gong

,yog

a,Pilates,

med

itatio

n,ed

ucationaltalks,

spatreatm

ents,m

assage

,bo

dytreatm

ents,cou

nseling

sessions,and

othe

rhe

aling

mod

alities.O

rganicdiet

with

mainlyplant-basedfood

s,somefishandeg

gprotein,

noadde

dsugaror

salt,no

gluten

,dairy,caffeine,

alcoho

l,redmeat,or

cann

edor

packaged

food

.

Gwingann

aLifestyle

Retreat,Tallebu

dgera

Valley,Queen

sland,

Australia

Pre-retreat,po

st-

retreat,6weeks

post-retreat.

Heigh

t,weigh

t,abdo

minalgirth,bloo

dpressure,urin

arype

sticide

metabolites;food

and

health

symptom

questio

nnaire,FiveFactor

WellnessInventory(FFW

),Pittsburgh

Insomnia

Ratin

gScale(PIRS),

Dep

ression,Anxiety

Stress

Scales

(DASS),Profile

ofMoo

dStates

(POMS),

Gen

eralized

Self-Efficacy

Scale(GSE),Health

Symptom

Questionn

aire

(HSQ

),andCog

state

cogn

itive

functio

ntest

battery.

Sig.

improvem

entsin

allanthrop

ometric

measures(p<0.001)

and

psycho

logicaland

health

measures(p<0.05)po

st-

retreatwith

atren

dfor

improved

health

symptom

frequ

ency

and

severity.Health

symptom

frequ

ency

andseverity

continuedto

improve

andbe

camestatistically

sig.

6-weeks

post-retreat,

othe

rmeasuresredu

ced

somew

hatandwereno

long

erstatisticallysig.,

even

thou

ghthey

remaine

dbe

low

pre-

retreatlevels.

Steinh

ubletal.,

2015

[20]

Observatio

nal

stud

yExpe

rienced

and

novice

med

itators

(n=40);Expe

rienced

(n=20),Novice

(n=20)

7-dayWellnessretreat:Silent

mantramed

itatio

n,talks,

guided

deep

breathing

exercise

(pranayama),yog

aandothe

ractivities

supp

ortin

ginne

rcalm

inindividu

alandgrou

psettings.

Retreatlocatio

nno

trepo

rted

,United

States

Preandpo

st-retreat

Heartrate

andhe

artrate

variability(HRV),mean

arterialp

ressure,

electroe

ncep

halograph

((EEG

);14

sensorsplus

2references)

Sig.,m

easureableEEG

change

sin

expe

rienced

andno

vice

med

itators.

Med

itatio

nwas

associated

with

asm

all,

butstatisticallysig.

Decreasein

bloo

dpressure

ina

norm

oten

sive

popu

latio

n.

Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 Page 8 of 17

Table

3Summaryof

Long

itudinalC

ohortStud

iesof

RetreatInterven

tions

(Con

tinued)

Reference

Stud

yde

sign

Popu

latio

n(includ

escomparatorgrou

p/s)

Interven

tion

Place(boldfont

indicatescoun

try)

Timingof

measures

OutcomeMeasures

Results

Hadgkisset

al.,

2013a[21];Li

etal.,2010

[22].

Long

itudinal

coho

rtstud

yMultip

leSclerosis

patients(n=274);

Nocomparator

5-dayLifestyleMod

ificatio

nRetreat:Low-fat,plant-based

diet,exercise,sunlight

expo

sure,vitamin

Dand

omeg

a-3supp

lemen

tatio

n.Educationalp

rogram

,med

itatio

nandstress

redu

ctiontechniqu

es,

coun

selling

,yog

aand

qigo

ng.

TheGaw

lerFound

ation,

Victoria,A

ustralia

Pre-retreatand1,

2.5and5years

postretreat

(2.5years

phased

out)

Health

-related

quality

oflife(HRQ

OL),M

ultip

leSclerosisQualityOfLife

Questionn

aire

(MSQ

OL-54)

Sig.

improvem

entsin

HRQ

OLinclud

ingoverall

quality

oflifedo

main

(p<0.001);physical

health

compo

site

(p<

0.001);and

men

talh

ealth

compo

site

(p<0.001).

Furthe

rim

provem

entsat

5yearsforoverallq

uality

oflife;ph

ysicalhe

alth

compo

site

andmen

tal

health

compo

site

Vella

&Bu

ddet

al.,

2011

[23]

Observatio

nal

stud

yFemalereastcancer

patients(n=28);No

comparator

7-dayPh

otog

raph

icArt

TherapyRetreat:Ph

otog

raph

icarttherapyinconcertwith

psycho

analyticallyoriented

grou

ptherapy,mind-bo

dypractices

(optionalyog

aand

meditatio

n),lectures,

discussio

nandsupp

ort

grou

psandverylow-fat

diet

andexercise.

F.Holland

Day

Cen

ter

forCreativity

and

Healing,

Geo

rgetow

n,Maine

,UnitedStates

Pre-retreat,po

st-

retreatand6weeks

post-retreat

Anxiety,d

epression,and

somaticsymptom

s(Brief

Symptom

Inventory-18

(BSI)),Qualityof

life

(Fun

ctionalA

ssessm

ent

ofCancerTherapy-

Gen

eral(FACT

-G)),

Spiritualwell-b

eing

(Fun

ctionalA

ssessm

ent

ofChron

icIllne

ssTherapy-Spiritual

Well-b

eing

(FACIT-sp)

subscale).

Sig.

redu

ctions

inde

pression

,anxiety

and

somaticstress

andsig.

Improvem

entsin

QoL

andspiritualwellbeing

that

weresustaine

dafter

6weeks.

Con

boyet

al.,

2009

[24]

Observatio

nal

stud

yWom

en(n=20);No

comparator

5-dayPanchakarm

aAyurved

icRetreatand3-

weeks

(Min.)Pre-Retreatand

2-weeks

Post-Retreat:

Individu

alassessmen

ts,

massage

treatm

ents,

cleansingdiet,yog

asession,cookingclass

andgrou

pdiscussion

.Pre-interven

tioninclud

esgu

idance

tomod

ifydiet

andbe

gintaking

common

herbalsupp

lemen

ts.Post-

interven

tioncontinuesthe

cleansingprocesswith

lifestylerecommen

datio

nsto

maintainbalancelong

term

.

KripaluCen

trefor

Yoga

andHealth

,UnitedStates

Pre-retreat,po

st-

retreatand3mon

ths

post-retreat

Health

-Promoting

LifestyleProfile,Q

uality

oflife(SF-12),Selfefficacy

(singlemeasure),Anxiety

(BeckAnxiety

Inventory),

Socialsupp

ort

(InterpersonalSup

port

Evaluatio

nListand

SarasonScoialSupp

ort

Questionn

aire),Perceived

Stress

Scale).

Sig.

improvem

entsin

self-

efficacytowards

using

Ayurved

ato

improve

health

with

sig.

Improvem

entsin

perceivedsocialsupp

ort

andde

pression

3mon

ths

post-retreat

Kenn

edyet

al.,

2003

[25]

Observatio

nal

stud

yRice

DietProg

ram

Participants(n=101);

Nocomparator

10-day

(Min.)Rice

Diet

Retreat:Very

low-fatdiet

andexercise.O

ptional

participationin

yoga

and

med

itatio

nclasses.Lectures,

Durham,N

orth

Carolina,United

States

Preandpo

st-retreat

Spirituality

(3item

questio

nnaire),well-b

eing

(12item

questio

nnaire),

meaning

inlife(1

item

Increasedspirituality

positivelyassociated

with

increasedwell-b

eing

,increasedsenseof

meaning

andpu

rpose

Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 Page 9 of 17

Table

3Summaryof

Long

itudinalC

ohortStud

iesof

RetreatInterven

tions

(Con

tinued)

Reference

Stud

yde

sign

Popu

latio

n(includ

escomparatorgrou

p/s)

Interven

tion

Place(boldfont

indicatescoun

try)

Timingof

measures

OutcomeMeasures

Results

discussion

andsupp

ort

grou

ps,including

adiscussion

grou

pon

spirituality.

questio

nnaire)andange

r(4

item

questio

nnaire).

inlife,andde

creased

tend

ency

tobe

come

angry.

Beatus

etal.,

2002

[26]

Observatio

nal

stud

yPeop

lewith

Multip

leSclerosis(n=41)

6-daysummer

retreat

offeredannu

allyby

The

Multip

leSclerosisSocietyto

individu

alswith

MS.The

retreaten

courages

physical

activity,art,and

social

interaction.

Specificlocatio

nno

tstated

,UnitedStates

Pre-

andpo

st-

retreat

Rosenb

urgSelf-Esteem

Scale(Self-E

),Multip

leSclerosisQualityof

Life-54

Instrumen

t(M

SQOL-54),

Activities

ofDailyLiving

(Activities

ofDailyLiving

SelfCareScalefor

person

swith

multip

lesclorisis(ADL-MS).

Sig.

increase

inthe

men

talcom

pone

ntof

quality

oflife.

Kenn

edyet

al.,

2002

[27]

Observatio

nal

stud

yPatientswith

coronary

diseaseandtheir

partne

rs(n=72);

Patients(n=51),

Partne

rs(n=21)

2.5-dayEducationalR

etreat

‘Cho

iceto

Review

’:Ope

ndiscussion

swith

healthcare

profession

als,activities

such

asstress-red

uctio

ntechniqu

es,(prog

ressive

relaxatio

n,yoga,b

reathing

exercises,visualization,and

imagery),exerciseop

tions,

nutrition

alcoun

selingand

vege

tarianfood

,group

exercisesthat

encourage

self-efficacy,en

hancesocial

supp

ort,bu

ildself-esteem

andim

provecommun

ication

skills,andspiritualprinciples

andtechniqu

esforhe

aling

(med

itatio

n,prayer

and

forgivesne

ss)

Remotelocatio

n,UnitedStates

Pre-retreat,po

st-

retreatand4–

6mon

thspo

st-

retreat

Spirituality

(3item

questio

nnaire),well-b

eing

(12item

questio

nnaire),

meaning

inlife(1

item

questio

nnaire)andange

r(4

item

questio

nnaire).

Chang

esin

spirituality

werepo

sitivelyassociated

with

increasedwell-b

eing

,meaning

inlife,and

confiden

cein

hand

ling

prob

lems,andwith

decreasedtend

ency

tobe

comeangry.Nosig.

Differen

ces4and

6mon

thspo

st-retreat.

Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 Page 10 of 17

ParticipantsStudies in this review included a wide range of demo-graphic and socioeconomic backgrounds including luxuryresort guests [12–15], teachers [16], human service profes-sionals [17], unemployed adults [18], and prison inmates[19, 20]. The reviewed studies also included participantswith a wide range of health conditions. Eleven studies re-cruited participants in general health [12–15, 21–26], fourstudies recruited participants with mental health issuessuch as stress, fatigue or burnout [17–20], four studies re-cruited participants with cancers including prostate can-cer, breast cancer and colon cancer [27–30], two studiesrecruited participants with multiple sclerosis [31–33], andthe remaining two studies recruited participants withHIV/AIDS [34], and cardiac conditions [35].The sample size in each study ranged from 14 [21] to

719 [16] with participants recruited from various loca-tions including the local community and neighbouringareas [13–15, 17, 18, 21], specific medical facilities [28,34, 36], prisons [19, 20], and secondary schools and col-leges [16]. In four studies, participants were guests whohad already registered to attend the retreat and were

invited to participate in the research [12, 22, 24, 25].Some studies did not report on how participants wererecruited [23, 27, 31, 33, 35].

InterventionsThe retreat length of stays ranged from two and a halfdays [17, 35] to 15 days [34] with a duration of five toseven days being the most common [12–16, 21–23, 26,28, 31–33, 36]. Four retreats included a follow-up inter-vention period [17, 23, 27, 30, 34] that ranged in fre-quency, duration and mode of delivery from a couple offour-hour sessions over 12 weeks [17] to weekly follow-up via telephone over a three-month period [27].Retreat programs ranged from a focus on religion and

spirituality to lifestyle, health and wellbeing. Spirituality-focused retreats involved different spiritual/religiousdenominations and practices including mindfulness medi-tation [13, 17, 18, 34], Vipassana meditation [16, 19, 20,25], Ayurveda [14, 15] and Ignatian/Jesuit spirituality [21].These retreats included activities such as prayer, mass,chanting, observing silence and other techniques such asbreathing and mindfulness. Health and wellness-focused

Table 4 Risk of bias summary for Randomised Controlled Trial Studies

Randomsequencegeneration(selection bias)

Allocationconcealment(selection bias)

Blinding ofparticipantsand personnel(performance bias)

Blinding ofoutcomeassessment(detection bias)Self-reportedoutcomes

Incompleteoutcome data(attrition bias)

Selectivereporting(reporting bias)

Other bias

Epel et al., 2016 [1] Low Unclear High High Low Unclear Low

Mills et al., 2016 [2] High High High High High Unclear Low

Peterson et al., 2016 [3] High High High Low Low Unclear Low

Taren et al., 2015 [4] Low High High High Low Unclear Low

Gilbert et al., 2014 [5] Low Unclear Unclear High Unclear Unclear Low

Pidgeon et al., 2014 [6] Low Unclear Unclear High High Unclear Low

Kwiatkowski et al., 2013 [7] Low Unclear Unclear High Low Unclear Low

Brazier et al., 2006 [8] [6] Low Unclear Unclear High Unclear Unclear Low

Table 5 Risk of bias summary for Non-Randomised Controlled Trial Studies

Bias due toconfounding

Bias in selection ofparticipants intothe study

Bias in classificationof interventions

Bias due todeviationsfrom intendedinterventions

Bias due tomissing data

Bias inmeasurementof outcomes

Bias inselection ofthe reportedresult

Al-Hussaini et al., 2001 [9] Low Low Low Low Low Moderate Low

Khurana & Dhar, 2000 [10] Low Low Low Low Low Moderate Low

Emavardhana & Tori, 1997 [11] Low Low Low Low Low Moderate Low

Chandiramani et al., 1995 [12] Low Low Low Low Low Moderate Low

Garland et al., 2009 [13];Garland, 2007 [14]; Angenet al., 2002 [15]

Low Low Low Low Low Moderate Low

Ornish et al., 2013 [16];Ornish et al., 2008 [17]

Low Low Low Low Low Low Low

Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 Page 11 of 17

retreats included activities such as exercise, yoga, bodytreatments, medical consultations, counselling, supportgroups and discussion [12, 22, 27, 31, 33]. Both spiritually-focused and health-focused retreats commonly includedmeditation as an activity, sometimes optional, along witha focus on either a prescribed diet such as organic diet,[12] vegetarian diet [15, 35] or low-fat diet, [24, 27, 28, 31,33] or dietary education such as mindful eating [16, 18] ornutritional counselling. [35] In the four studies with afollow-up intervention, activities included review andpractice of techniques taught at the retreat such as mind-fulness, [17, 34] the continuance of practices and pro-cesses that began at the retreat such as lifestyle changesand cleansing, [23] or telehealth support from a studynurse [27].

PlaceMore than half of the studies (13) were conducted in theUnited States [13–15, 18, 21–24, 27, 28, 35], three stud-ies were conducted in Australia [12, 17, 31, 33], twostudies each were conducted in Canada [29, 34, 36] andIndia [19, 20], and the remaining three studies were con-ducted in Oman [25], Thailand [16] and France [30].Studies were held at specifically designed retreat cen-

tres [34, 36], residential facilities such as religious cen-tres [16, 21] or prisons [19, 20] as well as yoga [23] andhealing retreat facilities [28]. Four studies were con-ducted with guests staying at luxury resorts, one inQueensland, Australia [12], and three at the same resortin California, United States [13–15]. Both studies con-ducted in India were conducted at a prison in New Delhifor prisoners [19, 20]. Three studies did not report thespecific location of the retreat [18, 22, 27].

ComparatorsOf the eight controlled trials reviewed, five included vac-ation groups [13–15, 18, 26], who visited the same

Table 6 Risk of bias summary for Longitudinal Cohort Studies

Bias due toconfounding

Bias in selectionof participantsinto the study

Bias inclassificationof interventions

Bias due todeviationsfrom intendedinterventions

Bias due tomissing data

Bias inmeasurementof outcomes

Bias in selectionof the reportedresult

Newberg et al., 2017 [18] Low Low Low Low Low Moderate Low

Cohen et al., 2017 [19] Low Low Low Low Low Moderate Low

Steinhubl et al., 2015 [20] Low Low Low Low Low Moderate Low

Hadgkiss et al., 2013a [21];Li et al., 2010 [22].

Low Low Low Low Low Moderate Low

Vella & Budd et al., 2011 [23] Low Low Low Low Low Moderate Low

Conboy et al., 2009 [24] Low Low Low Low Low Moderate Low

Kennedy et al., 2003 [25] Low Low Low Low Low Moderate Low

Beatus et al., 2002 [26] Low Low Low Low Low Moderate Low

Kennedy et al., 2002 [27] Low Low Low Low Low Moderate Low

4609 potentially relevant articles identified from searches until February 2017Medline 2315PsycINFO 915CINAHL 322

4505 articles excluded after title and abstract review or duplicates

103 articles retrieved for more detailed evaluationMedline 65PsycINFO 23CINAHL 15

75 articles excluded after full review as did not fulfil inclusion criteria ie. non-residential retreat study, no before/ after outcome data

8 RCTs8 Articles

9 Longitudinal Cohort Studies

17 Articles

8 Additional articles identified from references

(23 studies) 28 articles met inclusion criteria and included in review

6 Non-Randomised CTs

3 Articles

Fig. 1 Study Flow Chart

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retreat purely for relaxation purposes without participa-tion in organised retreat activities. One of these studiesincluded an additional comparator group to compare re-sults between novice and experienced meditators [13].One study for HIV/AIDS patients had a group who con-tinued to receive their standard care [34], and two stud-ies; one for Human Service Professionals and anotherfor non-metastatic breast cancer patients, had a groupwho received no intervention [17, 30].Of the six non-randomised controlled trials reviewed,

five studies included comparator groups who receivedno intervention [16, 19, 20, 25, 29] and one study in-cluded a group who received standard care [27]. Onlytwo of the nine longitudinal cohort studies included acomparator group, with one study comparing resultsfrom novice to experienced meditators [22] and anothercomparing results from healthy heart patients to theirpartners [35].

Outcome measuresAll studies reported statistically significant improve-ments in at least one measured outcome at some timeafter retreat. Outcomes ranged from subjective measuresusing standardized self-reported questionnaires for well-being [14, 36], quality of life [19, 28–30, 36] and per-ceived stress [12, 13, 18, 23, 26, 28, 34] such as; TheGratitude, Resentment and Appreciation Test (GRAT-sf ) [37, 38], The Ryff Scale of Psychological Wellbeing[39], and the Mental Health Index (MHI) [40]; to object-ive measures such as abdominal girth [12, 15, 27], bloodpressure [12, 15, 22, 27] and analysis of urine [12], blood[13–15, 26, 27], hair samples [18], neuroimaging [18],cognitive function [12], gene expression [13] and themetabolome [15]. All studies included at least one before(pre-retreat) and one after (post-retreat) measurementwith most studies including more than one post-retreat measurement, ranging from one month post-retreat [13, 14, 17, 36] to five years post-retreat [27, 31].No studies reported any adverse effects or economicoutcomes.

Summary of objective and subjective outcomesAll studies reported statistically significant improve-ments in at least one measured outcome with only onestudy of 44 human service professionals undertaking atwo-and-a-half day Mindfulness with Metta Training(MMTP) Retreat, reporting no significant differences inself-report measures of resilience, mindfulness and self-compassion immediately after the retreat experience,despite significant improvements for mindfulness andself-compassion at one and four months and for resili-ence at four months post-retreat [17]. A further study of47 patients with HIV/AIDS who participated in a 15-day‘Art-of-Living with HIV’ retreat reported significant

positive changes in wellbeing immediately after the re-treat, that were not evident after 6 and 12 weeks [34].

Objective/ quantitative outcomesAll seven studies investigating objective outcomes reportedstatistically significant improvements immediately after theintervention. Three of these studies reported significantimprovements in anthropometric measures such as weight,abdominal girth and blood pressure [12, 23, 27, 41] and re-ductions in blood lipids [41]. Statistically significant resultswere also reported for decreases in dopamine transporterbinding in the basal ganglia and serotonin transporterbinding in the midbrain [22]; changes in resting state func-tional connectivity (rsFC) in the right amygdala-subgenualanterior cingulate cortex (sgACC) [18]; reductions in 12phosphatidylcholines and an additional 57 metabolitessuch as amino acids, biogenic amines, acylcarnitines, gly-cerophospholipids and sphingolipids [15]; gene expressionchanges associated with improved regulation of stress re-sponse, immune function and amyloid beta (Aβ) metabol-ism [13]; and electroencephalogram (EEG) changes [22].Ornish et al. [27] further documented increases in relativetelomere length after five years that was associated withthe degree of adherence to lifestyle changes in ten of 35men with biopsy-proven prostate cancer [27, 41].

Subjective/ qualitative outcomesFifteen of the 16 studies investigating subjective or survey-based outcomes reported statistically-significant improve-ments immediately post-retreat including significant im-provements in quality of life, perceived physical health andhealth symptoms, as well as a variety of psychological andspiritual measures [12–14, 16, 17, 19–21, 23, 25, 28, 29, 31,34, 36]. Two studies reported improvements in overallhealth-related quality of life [28, 31] and four studies im-provements in perceived physical health [20, 21, 25, 31].Cohen et al. [12] reported improvements in both subjectiveand outcome measures including cognitive function andConboy et al. [23] reported improvements in positivehealth behaviours and self-efficacy.Eight of the nine studies measuring psychological well-

being reported statistically significant improvements in avariety of indicators including depression, anxiety, tension,stress, fatigue, mindful awareness and vitality [12, 13, 20,21, 25, 28, 29, 31, 36]. Khurana and Dhar [19] reportedimprovements in subjective wellbeing and criminal pro-pensity, however this improvement was only seen in maleinmates of the intervention group, and not in female in-mates or the control group that did not receive the inter-vention. All six studies measuring spiritual wellbeingreported significant improvements in various religious andspiritual measures [14, 16, 21, 24, 28, 35]. Vella and Budd[28] reported improvements in overall spiritual wellbeingand Mills et al. [14] reported a significant increase in

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spirituality and gratitude in the intervention group thatparticipated in a six-day Panchakarma Ayurvedic pro-gram, compared with no change in the control group thatwere on vacation at the same resort. Newberg et al. [21]reported significant changes such as more intense reli-gious and spiritual beliefs, feeling more religious and morespiritual, and an increase in feelings of self-transcendencein 14 participants of a Christian faith.Two studies [24, 35] investigating the relationship be-

tween spirituality and health measures, found that mea-sures of spirituality increased after a retreat along withincreased well-being, sense of meaning and purpose inlife, confidence in handling problems and a decreasedtendency to become angry. Similarly, Emavardhana andTori [16] found that heightened belief in Buddhist pre-cepts was associated with positive change in self-conceptand less self-criticism and increased Buddhist religiositywas correlated with reductions in the defences of dis-placement, projection and regression [16].

Risk of biasAll Randomised Controlled Trial Studies were found tohave low, unclear or high risk of bias in one or more do-mains. The most high risk was reported for blinding ofoutcome assessment. Allocation concealment and re-ported data selection was not reported for the majorityof studies and therefore unclear. All Non-RandomisedControlled Trial Studies and Longitudinal Cohort Stud-ies were found to have low risk of bias for all domainsexcept outcomes measures. All but one study [41] failedto report whether or not the outcomes assessor wasaware of the participant intervention and were thereforefound to have a moderate risk of bias for outcomesmeasurement. Given these findings, all studies are com-parable to a well-performed randomised trial with regardto the majority of domains (low risk) except outcomesmeasurement (moderate risk) indicating the studies aresound for a non-randomised study with regard to thisdomain but cannot be considered comparable to a well-performed randomized trial,

DiscussionThe retreat industry is a niche sector of the wellnesstourism industry that focuses on transformative experi-ences that aim to improve the health of participantsthrough healthy lifestyle experiences, along with provid-ing the skills and knowledge to help maintain healthybehaviours. The findings from the reviewed studies sug-gest there are many positive health benefits from retreatexperiences that includes improvements in both subject-ive and objective measures. Most studies used a quasi-experimental design with small sample sizes, poorlydescribed methodology with little follow-up data andreliance on self-report questionnaires to report on

psychological and spiritual benefits. The results from themost rigorous studies that used randomized controlleddesigns were consistent with less rigorous studies andsuggest that retreat experiences can produce benefitsthat include positive changes in metabolic and neuro-logical pathways, loss of weight, blood pressure andabdominal girth, reduction in health symptoms and im-provements in quality of life and subjective wellbeing.In addition to facilitating general health improve-

ments, there is evidence that retreat experiences canhave a positive impact on chronic disease processes andprovide benefits for some people with life threateningand/or chronic diseases. Of the four studies of retreatexperiences aimed at improving quality of life for cancerpatients [27, 28, 30, 36], all showed some benefits fromretreat participation, including improvements in qualityof life, depression and anxiety scores, and increased telo-mere length, with benefits being recorded up to fiveyears post-retreat. Similarly, benefits of retreat participa-tion are reported for people with multiple sclerosis withimprovements in quality of life along with physical andmental health being evident up to five years post-retreat[31, 32]. Not all measures in the studies of life-threatening chronic diseases improved [30, 36], and asthey are all small, poorly-controlled studies, more rigor-ous research is needed.The finding that retreat experiences can lead to sus-

tained and significant health improvements long afterparticipants return home suggests that these experiencesassist guests in making positive lifestyle changes andadopting healthy behaviours that lead to a variety ofpositive psychological, physiological, cognitive, clinicaland metabolic effects. The ability to influence partici-pants’ health once they return home is dependent onmany factors including the type of participants involved,the education and experiences provided during the re-treat program, and the provision of follow-up activitiessuch as online coaching, nutrition programs, or follow-up consultations with practitioners. Of the four studiesthat showed a reduced effect over time in some mea-sures [12, 17, 34, 35], two studies did not include afollow-up retreat component [12, 35].While it is not pos-sible to determine which parts of the retreat interventionhave the greatest influence, it is likely that improvementsin health are due to a combination of psychological andbehavioural factors that lead to better coping mecha-nisms and enhanced resilience to stress, as well as meta-bolic factors that lead to alterations in gene expressionand DNA repair mechanisms that are evident in the ob-served changes in the metabolome [15] and teleomerelength [27, 41].Despite the potential for retreat experiences to benefit

people with chronic and life threatening disease, the re-treat industry does not routinely interact with the health

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care sector with few patients being referred to retreatsby medical practitioners and retreat experiences gener-ally not covered by third party payment schemes or eli-gible for tax deductions or incentives. The lack ofintegration between the healthcare and retreat sectorsmay be partly due to a lack of data with which to evalu-ate retreat experiences. Few retreats routinely collectand/or communicate data relevant to the healthcaresector, and even when formal studies such as thosereviewed here are conducted, there is great heterogen-eity in the range and scope of outcome measures, withfew measures being comparable across studies. The re-treat industry would therefore benefit from the use of astandardised dataset collected from guests on a routinebasis. Such data could include a combination of psycho-logical, cognitive, physiological, anthropometric and bio-chemical measures that together provide a holisticassessment of outcomes. This would allow retreat partic-ipants to evaluate and monitor the impact of their expe-riences and provide data to engage the medicalprofession and third party payers. It would also be bene-ficial for the industry to develop a standardised reportingsystem for retreat activities so that the influence of dif-ferent types of retreat experiences can be assessed andresults meaningfully compared across retreats andstudies.While retreat experiences appear to have positive

health impacts, there is no published data on the eco-nomic impact of retreat experiences. There is however,substantial evidence that non-residential wellness pro-grams, which share a similar focus on health promotionand lifestyle modification, provide a substantial eco-nomic return [42–44]. A review of 28 studies of corpor-ate wellness programs [45] finds that the economicbenefit of participation is substantially higher than thecosts of providing the program. Stead [45] reportsbenefit-to-cost ratios averaging 3.4–1 which indicatesthat corporate companies receive on average US$3.40for every US$1 invested in the respective wellness pro-gram. In addition to return on investment, employeesbenefit from participating in corporate wellness pro-grams through experiencing better health, lowered dis-ability payments and reduced health care expenditures,while companies benefit from reduced employee turn-over, increased productivity [45] and reduced absentee-ism and presenteeism along with intangible benefitssuch as being an employer of choice and attractinghighly skilled employees and creating a positive corpor-ate culture [45, 46].While the economic benefits of corporate wellness

programs are becoming well established, it is unclear ifsimilar benefits are offered by residential retreats. Futurestudies that include a health economic analysis aretherefore needed to determine the cost-benefits of

retreat experiences and the return on investment forparticipants, businesses, health insurers and policymakers. This may enable retreat operators to advocatefor tax benefits, as well as inclusion in health insurancepolicies, and corporate wellness schemes. Furthermore,there is no data on the occurrence of adverse events. Fu-ture studies would benefit from including measures ofadverse outcomes to confirm the safety and efficacy ofretreat interventions.Despite the consistent reporting of positive health ef-

fects from retreat interventions across multiple study de-signs and locations, the ability to draw definitiveconclusions for any one condition or population is lim-ited due to poor methodological rigor and substantialheterogeneity in study design, length and type of retreatprogram, target population, outcome measures andlength of follow-up. Furthermore, while the reviewedstudies included subjects from a wide range of demo-graphic groups in multiple countries, only publishedEnglish language studies were reviewed and it is uncer-tain if the findings can be generalized to the wider popu-lation. The use of mostly self-selected populations alsointroduces the possibility of selection bias, while a lackof blinding and adequate controls may introduce per-formance bias due to exposure to factors other than thespecific intervention such as the vacation effect wherebyhealth can improve from simply being removed fromnormal routines and behaviours. The lack of any re-ported adverse events may further indicate reportingbias with researchers not actively looking to identify ad-verse outcomes, or outcome measurement tools not be-ing designed to capture adverse outcomes. Futurestudies, with more rigorous methodology and long-termfollow-ups are now needed to determine the longevity ofany effects, their mechanisms of action and the condi-tions most likely to respond.

ConclusionThe findings of this review suggest that retreat experi-ences appear to have positive health benefits that includebenefits for people with chronic diseases. As the ob-served improvements in chronic diseases are based on asmall number of patients, future research using largernumbers of subjects and longer follow-up periods isneeded in order to determine the populations mostlikely to benefit and quantify any long-term health bene-fits. Future studies could also benefit from more rigor-ous study designs including the use of standardizedoutcome measures, more detailed descriptions of the re-treat interventions and study population, and the inclu-sion of a health economics analysis in order todetermine the economic benefits of retreat experiencesfor individuals, as well as for businesses, health insurersand policy makers.

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AbbreviationsAβ: Amyloid Beta; BMI: Body Mass Index; BP: Blood Pressure;DNA: Deoxyribonucleic Acid; EEG: Electroencephalogram; GRAT-sf: TheGratitude, Resentment and Appreciation Test; HIV/AIDS: HumanImmunodeficiency Virus and Acquired Immune Deficiency Syndrome;MHI: Mental Health Index; MS: Multiple Sclerosis; MTTP: Mindfulness withMeta Training Program; PICOS: Participant, Intervention, Comparators,Outcomes and Study Design); PwMS: People with Multiple Sclerosis;RCT: Randomised Controlled Trial; RsFC: Resting state functional connectivity;SgACC: subgenual anterior cingulate cortex; WHO: World Health Organisation

AcknowledgementsThere are no specific acknowledgements to make.

FundingThe authors of this study have not received any funding to support thisSystematic Review.

Availability of data and materialsThe data for this paper was obtained from published papers reported in thereference section and as such, has not been placed in a data repository.

Authors’ contributionsDN contributed to the planning and design of the methodology for thissystematic review. DN conducted the searches to find appropriate papers forthis systematic review. DN appraised papers to determine whether or notthey met criteria to be included in this review. DN extracted data from thepapers. DN conducted searches to find background material for this paper.DN undertook the initial write-up of all sections of this paper includingreferencing. DN corresponded with the other authors to obtain reviewand comments on this paper. DN revised several versions of this paper.MC led the planning and design of the methodology for this systematicreview. MC reviewed all papers in this review according to the inclusioncriteria. MC led meetings between DN, MC and AS regarding the methodology,data extraction, write-up and preparation of this paper. MC reviewed this paperon several occasions including revision of all materials. AS reviewed themethodology for this systematic review. AS contributed to the discussionand planning of preparing this paper. AS reviewed this paper and includedcomment, feedback and multiple revisions. All authors read and approved thefinal manuscript.

Authors’ informationMC is a Registered Medical Practitioner, Professor of Health Sciences at RMITUniversity and a Board Member at the Global Wellness Summit.AS is a Clinical Psychologist and an employee of Cogstate.DN holds a Bachelor degree in Health Science from the University ofAuckland and is undertaking an Honours in Health and Biomedical Sciencesat RMIT University.

Ethics approval and consent to participateAs this paper describes literature-based research, ethics approval is notrelevant.

Consent for publicationNot applicable.

Competing interestsMC is a board member of the Global Wellness Summit and has previouslybeen a paid presenter at the Gwinganna Health Retreat. RMIT University hasreceived donations from Danubius Hotel Group, Lapinha, Sunswept Resorts,Sheenjoy and The Golden Door for ongoing retreat research.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims in publishedmaps and institutional affiliations.

Author details1School of Health and Biomedical Sciences, RMIT University, Plenty Rd,Bundoora, Bundoora, VIC 3083, Australia. 2Cogstate Limited, Melbourne 3000,Australia.

Received: 3 August 2017 Accepted: 29 December 2017

References1. World Health Organisation. Preventing Chronic Diseases. A Vital Investment:

WHO Global Report., Geneva: World Health Organization. . 2005. www.who.int/chp/chronic_disease_report/en.

2. Smith M, Kelly C. Holistic tourism: journeys of the self? Tour Recreat Res.2006a;31(1):15–24. https://doi.org/10.1080/02508281.2006.11081243.

3. Smith M. Holistic holidays: tourism and the reconciliation of body, mind andSpirit. Tour Recreat Res. 2003;28(1):103–8. https://doi.org/10.1080/02508281.2003.11081392.

4. Smith M, Kelly C. Wellness tourism. Tour Recreat Res. 2006b;31(1):1–4.https://doi.org/10.1080/02508281.2006.11081241.

5. Gesler WM. Therapeutic landscapes: medical issues in light of the newcultural geography. Social science &amp; medicine (1982). 1992;34(7):735.

6. Yeung O, Johnston K. Global wellness economy monitor. Miami, Fl: GlobalWellness Institute2017.

7. Yeung O, Johnston K. The Global Wellness Tourism Economy. Miami, Fl:Global Wellness Institute 2014 March 1 2017.

8. Lea J. Retreating to nature: rethinking ‘therapeutic landscapes. Area. 2008;40(1):90–8. https://doi.org/10.1111/j.1475-4762.2008.00789.x.

9. Kelly C. Wellness tourism: retreat visitor motivations and experiences. TourRecreat Res. 2012;37(3):205–13. https://doi.org/10.1080/02508281.2012.11081709.

10. Methley AM, Campbell S, Chew-Graham C, McNally R, Cheraghi-Sohi SPICO.PICOS and SPIDER: a comparison study of specificity and sensitivity in threesearch tools for qualitative systematic reviews. BMC Health Serv Res. 2014;14(1):579. https://doi.org/10.1186/s12913-014-0579-0.

11. Higgins JP, Green S, editors. Cochrane Handbook for Systematic Reviews ofInterventions Version 5.1.0 [updated March 2011]. The CochraneCollaboration; 2011.

12. Cohen MM, Elliott F, Oates L, Schembri A, Mantri N. Do Wellness TouristsGet Well? An Observational Study of Multiple Dimensions of Health andWell-Being After a Week-Long Retreat. Journal of alternative andcomplementary medicine (New York, NY). 2017;23(2):140–8. https://doi.org/10.1089/acm.2016.0268.

13. Epel ES, Puterman E, Lin J, Blackburn EH, Lum PY, Beckmann ND, et al.Meditation and vacation effects have an impact on disease-associatedmolecular phenotypes. Transl Psychiatry. 2016;6:e880. https://doi.org/10.1038/tp.2016.164.

14. Mills PJ, Wilson KL, Pung MA, Weiss L, Patel S, Doraiswamy PM, et al. Theself-directed biological transformation initiative and well-being. The Journalof Alternative and Complementary Medicine. 2016;22(8):627–34. https://doi.org/10.1089/acm.2016.0002.

15. Peterson CT, Lucas J, John-Williams LS, Thompson JW, Moseley MA, Patel Set al. Identification of altered Metabolomic profiles following aPanchakarma-based Ayurvedic intervention in healthy subjects: the self-directed biological transformation initiative (SBTI). Sci Rep 2016;6:32609.https://doi.org/10.1038/srep32609. http://www.nature.com/articles/srep32609 - supplementary-information.

16. Emavardhana T, Tori CD. Changes in self-concept, ego defense mechanismsand religiosity following seven-day Vispassana meditation retreats. TheJournal for the Scientific Study of Religion. 1997;36(2):194–206.

17. Pidgeon AM, Ford L, Klaassen F. Evaluating the effectiveness ofenhancing resilience in human service professionals using a retreat-based mindfulness with Metta training program: a randomised controltrial. Psychology, health & medicine. 2014;19(3):355–64. https://doi.org/10.1080/13548506.2013.806815.

18. Taren AA, Gianaros PJ, Greco CM, Lindsay EK, Fairgrieve A, Brown KW, et al.Mindfulness meditation training alters stress-related amygdala resting statefunctional connectivity: a randomized controlled trial. Soc Cogn AffectNeurosci. 2015;10(12):1758–68. https://doi.org/10.1093/scan/nsv066.

19. Khurana A, Dhar PL. Effect of Vipassana meditation on quality of life,subjective well-being, and criminal propensity among inmates of Tiharjail, Delhi. New Delhi, Vipassana Research Institute: Indian Institute ofTechnology; 2000. http://www.vridhamma.org/Research-on-inmates-of-Tihar-Jail-Delhi

20. Chandiramani K, Verma SK, Dhar PL, and Agarwal N. Psychological effects ofVipassana on Tihar jail inmates: research report. Vipassana Research Institute1995. http://www.vridhamma.org/Psychological-effects-on-tihar-jail-inmates.

Naidoo et al. BMC Complementary and Alternative Medicine (2018) 18:8 Page 16 of 17

21. Newberg AB, Wintering N, Yaden DB, Zhong L, Bowen B, Averick N, et al. Effectof a one-week spiritual retreat on dopamine and serotonin transporterbinding: a preliminary study. Religion, Brain & Behavior. 2017:1–14. https://doi.org/10.1080/2153599X.2016.1267035.

22. Steinhubl SR, Wineinger NE, Patel S, Boeldt DL, Mackellar G, Porter V, et al.Cardiovascular and nervous system changes during meditation. Frontiers inHuman Neuroscience. 2015, 9;(145) https://doi.org/10.3389/fnhum.2015.00145.

23. Conboy LA, Edshteyn I, Garivaltis H. Ayurveda and Panchakarma: measuringthe effects of a holistic health intervention. TheScientificWorldJOURNAL.2009;9:272–80. https://doi.org/10.1100/tsw.2009.35.

24. Kennedy JE, Rosati KG, Spann LH, King AD, Neelon FA, Rosati RA. Changesin spirituality and well-being in a medically based lifestyle program. 2003.http://jeksite.org/research/riceup.pdf

25. Al-Hussaini AA, Dorvlo ASS, Antony SX, Chavan D, Dave J, Purecha V, et al.Vipassana meditation:: A naturalistic, preliminary observation in Muscat.Journal for scientific research Medical sciences / Sultan Qaboos University.2001;3(2):87–92.

26. Gilbert A, Epel E, Tanzi R, Rearden R, Schilf S, Puterman E. A RandomizedTrial Comparing a Brief Meditation Retreat to a Vacation: Effects on DailyWell-Being. The Journal of Alternative and Complementary Medicine. 2014;20(5):A92–A. https://doi.org/10.1089/acm.2014.5242.abstract.

27. Ornish D, Lin J, Chan JM, Epel E, Kemp C, Weidner G, et al. Effect ofcomprehensive lifestyle changes on telomerase activity and telomerelength in men with biopsy-proven low-risk prostate cancer: 5-year follow-upof a descriptive pilot study. The Lancet Oncology. 2013;14(11):1112–20.https://doi.org/10.1016/s1470-2045(13)70366-8.

28. Vella EJ, Budd M. Pilot study: retreat intervention predicts improved qualityof life and reduced psychological distress among breast cancer patients.Complement Ther Clin Pract. 2011;17(4):209–14. https://doi.org/10.1016/j.ctcp.2011.01.005.

29. Garland S, Carlson L, Marr H, Simpson S. Recruitment and retention ofpalliative cancer patients and their partners participating in a longitudinalevaluation of a psychosocial retreat program. Palliative & Supportive Care.2009;7(1):49–56.

30. Kwiatkowski F, Mouret-Reynier MA, Duclos M, Leger-Enreille A, Bridon F,Hahn T, et al. Long term improved quality of life by a 2-week groupphysical and educational intervention shortly after breast cancerchemotherapy completion. Results of the ‘Programme of accompanyingwomen after breast cancer treatment completion in thermal resorts’(PACThe) randomised clinical trial of 251 patients. Eur J Cancer. 2013;49(7):1530–8. https://doi.org/10.1016/j.ejca.2012.12.021.

31. Hadgkiss EJ, Jelinek GA, Weiland TJ, Rumbold G, Mackinlay CA, Gutbrod S,et al. Health-related quality of life outcomes at 1 and 5 years after aresidential retreat promoting lifestyle modification for people with multiplesclerosis. Neurological sciences : official journal of the Italian NeurologicalSociety and of the Italian Society of Clinical Neurophysiology. 2013a;34(2):187–95. https://doi.org/10.1007/s10072-012-0982-4.

32. Beatus J, O'Neill JK, Townsend T, Robrecht K. The effect of a one-weekretreat on self-esteem, quality of life, and functional ability for persons withmultiple sclerosis. J Neurol Phys Ther. 2002;26(3):154–9.

33. Li MP, Jelinek GA, Weiland TJ, Mackinlay CA, Dye S, Gawler I. Effect of aresidential retreat promoting lifestyle modifications on health-related qualityof life in people with multiple sclerosis. Qual Prim Care. 2010;18(6):379–89.

34. Brazier A, Mulkins A, Verhoef M. Evaluating a yogic breathing andmeditation intervention for individuals living with HIV/AIDS. Americanjournal of health promotion : AJHP. 2006;20(3):192–5.

35. Kennedy JE, Abbott RA, Rosenberg BS. Changes in spirituality and well-beingin a retreat program for cardiac patients. Altern Ther Health Med. 2002;8(4):64. -6, 8-70, 2-3

36. Garland S. A pilot project to assess the impact of a psychosocial retreatintervention on the quality of life, distress, marital satisfaction and existentialconcerns in palliative cancer patients and their partners: ProQuestDissertations Publishing; 2007.

37. Froh JJ, Fan J, Emmons RA, Bono G, Huebner ES, Watkins P. Measuringgratitude in youth: assessing the psychometric properties of adult gratitudescales in children and adolescents. Psychol Assess. 2011;23(2):311–24.https://doi.org/10.1037/a0021590.

38. McCullough ME, Emmons RA, Tsang JA. The grateful disposition: aconceptual and empirical topography. J Pers Soc Psychol. 2002;82(1):112–27.

39. Ryff CD, Singer B. Psychological well-being: meaning, measurement, andimplications for psychotherapy research. Psychother Psychosom. 1996;65(1):14–23.

40. Veit CT, Ware JE Jr. The structure of psychological distress and well-being ingeneral populations. J Consult Clin Psychol. 1983;51(5):730–42.

41. Ornish D, Magbanua MJM, Weidner G, Weinberg V, Kemp C, Green C, et al.Changes in prostate gene expression in men undergoing an intensivenutrition and lifestyle intervention. Proc Natl Acad Sci U S A. 2008;105(24):8369–74. https://doi.org/10.1073/pnas.0803080105.

42. Minter SG. Tenneco: pursuing health for the long term. Occupational Hazards.1996;58(4):53.

43. Fries JF, Koop CE, Beadle CE, Cooper PP, England MJ, Greaves RF, et al.Reducing health care costs by reducing the need and demand for medicalservices. N Engl J Med. 1993;329(5):321–5.

44. Wolfe R, Parker D, Napier N. Employee health management and organizationalperformance. J Appl Behav Sci. 1994;30(1):22–42. https://doi.org/10.1177/0021886394301002.

45. Stead BA. Worksite health programs: A significant cost-cutting approach.Business Horizons. 1994 1994/11/01:73–8.

46. Ho JTS. Corporate wellness programmes in Singapore: effect on stress,satisfaction and absenteeism. J Manag Psychol. 1997;12(3):177–89.https://doi.org/10.1108/02683949710174801.

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