key: cord-0258587-beb0nzyf authors: Wang, C.; Pearce, E.; Jones, R.; Lloyd-Evans, B. title: Kindness By Post: A Mixed-Methods Evaluation of A Participatory Public Mental Health Project date: 2021-11-19 journal: nan DOI: 10.1101/2021.11.19.21266589 sha: 5ff7eb61d825ed3ce79f1d47cee93223df119108 doc_id: 258587 cord_uid: beb0nzyf Background: Random acts of kindness can improve wellbeing. However, less is known about the impacts of giving and receiving acts of kindness with strangers on wellbeing and loneliness. Therefore, the study objectives were to evaluate a participatory public mental health project involving sending and receiving a card with goodwill messages, to understand how such acts of kindness influence wellbeing and loneliness, and to investigate the potential mechanisms underlying the impacts of the project. Materials and methods: This study was a secondary analysis of anonymised service evaluation data collected in the Kindness by Post (KBP) project in 2020. It used a mixed-methods single-group design and data from 289 participants. Changes in wellbeing, loneliness, sense of belonging and hope from baseline to follow-up were analysed using linear or multinomial logistic regression. Regression models also examined the associations between changes in wellbeing and baseline loneliness or participation level. Free text responses about experiences and suggestions for the project were analysed using thematic analysis. Results: Participants had a small, but statistically significant improvement, in wellbeing equating to 0.21 standard deviations (SD) (95% CI: 0.12 to 0.30) after taking part in the project, as well as improvements in loneliness, sense of belonging and hope. How lonely a participant was at baseline and whether participants both sent and received a kindness card were not associated with improvements in wellbeing. In the qualitative analysis, a desire to help others emerged as the main motivator to take part in the card exchange. Participants reported enhanced personal fulfilment, leading to improvements in wellbeing. Receiving a card could make people feel special and cherished, which was reported to establish a sense of connection with others, with potential benefits for reducing loneliness. Conclusions: This study provided preliminary evidence that the KBP project might improve wellbeing, loneliness, sense of belonging and hope. Sending a kindness card in this project played a predominant role in wellbeing enhancement, and receiving a kindness card could reduce loneliness. This study suggests that the KBP project can be replicated in more contexts in the future, and might improve wellbeing and loneliness in large communities. strangers and enhancement of people's wellbeing. Therefore, it is essential to further investigate the 129 experiences of kind acts for improving wellbeing. Furthermore, kindness behaviours can provide social 130 support in which people encounter social interactions. Cacioppo et al (2015) noted that actions that 131 provide mutual social support and increase social interactions with others could reduce loneliness. 132 Concerning the strong associations between loneliness and wellbeing (Emerson et al., 2020; Houghton 133 et al., 2016), it is also worth determining whether simple kindness behaviours could build 134 connectedness between individuals, which may be an effective means to reduce loneliness. This study will add to the developing evidence base regarding acts of kindness to and from strangers 137 in promoting wellbeing and reducing loneliness. It aims to examine the effectiveness of a brief, self- Valentine's Day period (Otnes et al., 1994) . The KBP project mobilises several mechanisms for 149 improving wellbeing, discussed above. First, it involves an act of kindness to a stranger, which has an 150 established evidence base for improving wellbeing. Second, in contrast to most random acts of 151 kindness projects, KBP also has a reciprocal element of giving and receiving, which may increase 152 connections with others. Third, the creative element of card-making and kind message-writing in KBP 153 may also be helpful for wellbeing promotion. As an inexpensive, potentially highly scalable 154 programme, it is therefore of substantial interest to evaluate the KBP project and understand how it is 155 experienced by participants. 156 of this programme, its perceived benefits and the potential mechanisms by which any perceived effects 173 may have been achieved. All participants in GBV who completed pre-and post-outcome measures were included in this study. 183 To take part in GBV, people had to be aged 16 years or above with a postal address in the UK; there 184 were no other exclusion criteria. Participants were required to sign up for GBV online. Consistent with 185 our ethical approval, the current study only used the data from the adult participants, aged 18 or above. The GBV card exchange was broadly advertised in newspapers, broadcast and social media. People 193 who were interested in this project could sign up on the MHC website. Participants registered to take 194 part were first invited to complete the 'Before questionnaire' online. They were informed that the data 195 could be shared with external organisations anonymously for research purposes. People gave their 196 consent to this by proceeding with the questionnaire. The baseline data collection was conducted from 197 the 12 th of January to the 14 th of February 2020. One week before Valentine's Day, each participant 198 was asked to send a homemade card or letter with goodwill messages to a stranger who was randomly 199 allocated by a computer algorithm. The stranger's postal address and instructions regarding how to 200 send a card were sent to the participant's account. In return, each participant would receive a card from 201 another stranger during the week of Valentine's Day. If participants had not received a card, there was 202 a back-up system that allowed participants to ask the programme organisers to arrange for a 203 'replacement' card from a volunteer. Participants were informed that there was no guarantee of 204 receiving a card because the sending process from the stranger was completely voluntary, and not 205 receiving a card was nothing personal. Participants could withdraw from the project at any time they 206 wished. After the card exchange, participants were contacted again by email on the 26 th February and 207 invited to complete the online 'After Questionnaire'. They were reminded again about their 208 anonymised data being shared and that they could give their consent by completing the questionnaire. Participants were sent a second reminder by email if they did not respond to the questionnaires. The is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint • Hope, using a single item from the Beck Depression Inventory (Beck et al., 1996) . Participants reported their gender, ethnicity and age group at baseline. They reported whether or not 224 they had sent and had received a card and provided brief free-text feedback about their experiences of 225 the project at follow-up. There were four questions covering the specific sending or receiving 226 experiences as well as their overall impressions and suggestions for the project. Further information 227 regarding the study measures and how they were scored is provided in supplementary material 1. All data were downloaded into a Microsoft Excel file by KBP staff. Free-text data were checked to 230 remove any personally identifying information, such as names. Multiple and duplicate responses from 231 the same person were identified by checking the sources such as email addresses of the responses. For 232 participants who completed the measures more than once at the same timepoint in either before-or 233 after-questionnaires, all their responses were removed, unless the responses at the same timepoint were 234 identical, then one of the responses was saved. An anonymised dataset was thus produced, containing 235 no personal identifiers or codes that could be used to link the data back to identifiable individuals. This 236 anonymised dataset was then shared with the researcher at UCL through the secure UCL Dropbox 237 system. 2.6 Quantitative analysis 240 We summarise demographic characteristics of the sample as well as baseline and follow up measures 241 of wellbeing, loneliness, sense of belonging and hope using descriptive statistics. To explore how 242 representative our sample was of GBV participants, we compared participants who had completed 243 both before and after questionnaires with those who had only completed the before questionnaire 244 using linear regression and chi squared tests. We calculated standardised scores for wellbeing, loneliness and sense of belonging at baseline and is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint To explore whether the programme's effectiveness was associated with either baseline loneliness or 263 full vs partial participation, we fitted separate univariable linear regression models with change in 264 wellbeing as the outcome and baseline loneliness and participation level respectively as the single 265 explanatory variable. We checked the assumptions of regression models through the construction of 266 appropriate histograms and normal quantile plots. All analyses were performed using Stata v16. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 19, 2021. ; https://doi.org/10.1101/2021.11.19.21266589 doi: medRxiv preprint Codes relevant to the research questions were generated inductively and deductively based on the 304 semantic meaning of the responses and the latent meaning or the interpretation of the contents. The 305 codes could be modified iteratively throughout the coding process to accommodate new ideas. After 306 the codes were created, a cluster of codes sharing unifying features were combined into a higher-level 307 subtheme or theme depending on how well it described a coherent and meaningful pattern in the data. 308 The codes arising from the transcripts and the theme framework were discussed with other researchers 309 to achieve a consensus, which would enhance the trustworthiness and credibility of the results. Themes Hardly anybody (N=6) received a card but did not send one. Compared to the people who only 331 completed the before-questionnaire, participants completing both questionnaires were generally older 332 and had a lower baseline sense of belonging. There was also weak evidence that more completers were 333 female. There was no evidence of any other differences between completers and non-completers. Table 334 1 shows participants' descriptive statistics summarised according to completer status. There was no evidence that baseline loneliness was associated with wellbeing improvements (p=0.732) 358 or that level of participation in the project was related to wellbeing changes (p=0.556). Please see Table 359 3 for further details. Many participants mentioned that they enjoyed the processes of making a card because they could 398 slow down and spend time being creative and making artistic items. This process promoted self-care. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint Overall, few substantial differences were observed in participants' programme experiences with 468 different participation levels (sent and received/sent but not received/not sent but received). However, 469 among the six participants who did not send but did receive a card, none of them identified the project hope for the future than a loss of hope. Contrary to the hypotheses, the results provided no evidence 487 that the level of loneliness at baseline affected the impacts of GBV on participants' wellbeing. There could increase personal fulfilment by thinking that they were performing a significantly meaningful 506 task to help others, increasing their self-esteem and happiness. This finding aligns with the previous 507 literature noting that people could derive satisfaction and gain more resources from the kindness 508 behaviours that help others, which makes them happy (Curry et al., 2018, p11). The findings also illustrated that enjoyment in making cards allowed people respite from the pressures 511 of life and spend time being creative, which promoted self-care and made them feel joyful. This This study is novel in utilising a mixed-methods design to understand how kindness acts in a public 538 mental health project improve wellbeing and reduce loneliness for both the giver and the receiver. It 539 provides insight into the potential mechanisms explaining which components in the kind acts could 540 enhance wellbeing and reduce loneliness. It also has the significant advantage of using nationwide data 541 to explore the effectiveness of a public programme involving acts of kindness for promoting general 542 wellbeing and social connection in a large social community. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 19, 2021. ; https://doi.org/10.1101/2021.11.19.21266589 doi: medRxiv preprint with the flourish of spring. Regarding the study measures: to maintain a good response rate, the questionnaire was designed to be 552 sufficiently brief to capture the four individual outcomes (Edwards et al., 2002) . Thus, there were a 553 limited number of questions extracted from the structured measures for belongingness and hope, which 554 might potentially reduce the measures' reliability (Goodman et al., 2015) . This brief-measure issue 555 was particularly prominent when analysing hope. Merely including a single item made it less sensitive 556 for discriminating the change in hope over time, which might explain why most participants reported 557 no change in hope. Moreover, this study only used brief online free-text responses for the qualitative 558 analysis. The content in these materials was not always clear or in-depth; hence, it might be difficult 559 to capture a full understanding of the experiences of the project. Regarding the participants of KBP, participants in the current datasets were mostly white and female, 562 potentially because the project was called 'Great British Valentines', which failed to attract some ethnic 563 minority groups from distinct cultures or religions that do not celebrate Valentine's Day. Therefore, the 564 results might not generalise to ethnic minorities or to men. In addition, the insufficient number of 565 people from non-White British ethnic groups does not allow us to explore whether this cultural 566 homogeneity may enhance the programme's effects, if a card is received from someone with some 567 shared cultural experience and perspectives, or conversely whether exchanges with people different 568 from oneself are even more connecting and powerful. Furthermore, we lacked data about other 569 characteristics of interest for participants, for instance their socio-economic or marital/partnership 570 status, with which to describe our sample or explore potential moderators of the programme's effects. Regarding the data available to the researchers, participants who continued to complete the 572 questionnaire at follow-up were generally older and had a lower level of belongingness than those who 573 only completed the baseline measures. Therefore, there might be an attrition bias in the study data. Additionally, there were only six people who did not send but received a card. Therefore, this study 575 might miss the experiences shared by this group, and whether the KBP helped them was unclear. Finally, the collection date for the 'After questionnaire' was only one week after the intervention. This 577 study does not tell us whether the enhancement in wellbeing and decrease in loneliness due to this 578 project would be maintained over the longer term. The current study has shown that the KPB project has the potential to enhance wellbeing and reduce 584 loneliness for the general population. This supports providing more KBP card exchanges in more 585 contexts in the future, particularly during periods when people are vulnerable to mental or physical is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 19, 2021. ; https://doi.org/10.1101/2021.11.19.21266589 doi: medRxiv preprint strengthening the back-up system to provide an additional card may be helpful, to ensure that everyone 594 could receive a card. It may also be helpful to set up a way for participants to confirm online that they 595 have sent a card; otherwise, they could receive a reminder. Additionally, it might be helpful for 596 participants to know whether their card was received by the recipient in a direct or indirect feedback 597 system. People may derive satisfaction from their kindness behaviours that are appreciated by others, 598 potentially enhancing the project's effectiveness (Curry et al., 2018, p11; Ouweneel et al., 2014) . Acknowledgements: 836 We thank Dr Amy Pollard, the Director of the Mental Health Collective and organiser of the 'Kindness 837 by Post' project, for her support for this study, for providing access to the study data and for 838 contributing to development of themes for the qualitative analysis. 839 We also extend thanks to the participants for contributing their data to the current research. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint coded as 0, 1, 2 and 3 , and greater score means higher level of hope. . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 19, 2021. ; https://doi.org/10.1101/2021.11.19.21266589 doi: medRxiv preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 19, 2021. ; https://doi.org/10.1101/2021.11.19.21266589 doi: medRxiv preprint . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted November 19, 2021. ; https://doi.org/10.1101/2021.11.19.21266589 doi: medRxiv preprint . 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