Allergic rhinitis in children is a common chronic disease in childhood and adolescence in China, and it affects about 14% of children worldwide (Aït-Khaled et al., 2009; Li et al., 2011). Allergic rhinitis in children may cause many complications, including allergic asthma, allergic conjunctivitis and atopic dermatitis (Hellings and Fokkens, 2006; Siddiqui et al., 2022), which may seriously affect children’s sleep quality, learning and even growth and development. Since the main caregivers of the children with chronic disease take almost full responsibility for the care, in addition to daily care, caregivers also need to complete special care related to disease, including continuous supervision, treatment management and medication of the children (Drotar, 1981). These heavy care burden increase their stress, and the stress will have psychological, social, and even physical impact on the caregivers of the children with chronic disease (Zahr et al., 1994; Pinquart and Sorensen, 2003). Previous studies have well illustrated the anxiety and depression level of children with chronic diseases are significantly increased (van Oers et al., 2014). Thus, the mental health status of main caregivers of children with allergic rhinitis requires full attention.

There are worldwide studies targeting caregivers of children with chronic illness, which include skill trainings, environment changes, psychological interventions, physical excercises and group trainings (Sheng et al., 2019; Olij et al., 2021). Our study focus on the psychological interventions. The common psychological interventions which can elevate mental well-being include acceptance and commitment therapy (ACT), compassion interventions, cognitive therapy, expressive writing, mindfulness-based interventions (MBIs), positive psychological interventions (PPIs) and etc. In these interventions mentioned above, MBIs and PPIs can improve mental health of well-being across populations, including the general population and clinical population (van Agteren et al., 2021).

Mindfulness-based interventions (MBIs) have their roots in Buddhist tradition tracing back to 2,500 years ago. Systematic mindfulness-based therapy began in1979, Dr. Kabat-Zinn from the Massachusetts Medical School designed the Mindfulness-Based Stress Reduction (MBSR) therapy (Kabat-Zinn, 1990). Thereafter, MBIs have been integrated into various therapy, including Mindfulness-Based Stress Reduction (MBSR), Mindfulness-Based Cognitive Therapy (MBCT; Segal et al., 2002), Dialectical Behavior Therapy (DBT; Linehan, 1993) and Acceptance and Commitment Therapy (ACT; Hayes et al., 1999). With the rapid development of information technology, numerous psycho-therapeutic interventions, including MBIs, are conducted through the Internet. Accessible, available in participants’ own environment, anonymous and less costly, online MBIs is booming in the past decades via various electronic devices. Meta analyses have indicated the impact of online MBIs is compatible to the traditional face-to-face format on mental health outcomes, including stress, depression, anxiety and mindfulness (Spijkerman et al., 2016; Sommers-Spijkerman et al., 2021).

Mindfulness-Based Cognitive Therapy (MBCT) is a group-based intervention constructed by Teasdale et al., initially for prevention of relapses from depression (Segal et al., 2013). The practices of mindfulness in the MBCT program helps participants disengage with the patterns of negative thinking by increasing their awareness of their internal thoughts, emotions and bodily sensations at the present moment, together with a non-judgmental and accepting state of mind (Segal et al., 2013). Since the efficacy of MBCT first confirmed in 2000 (Teasdale et al., 2000), there has been accelerating interest in applying mindfulness in medical treatment (Sipe and Eisendrath, 2012). Besides clinical application in psychiatric disorders, cancer, pain, diabetes and etc., MBCT program has been used as a treatment to improve the mental health and well-being in the general populations, as well as the elderly population (Chiesa and Serretti, 2011; Querstret et al., 2018; Hazlett-Stevens et al., 2019; Ni et al., 2020; Pei et al., 2021; Lin et al., 2022). A RCT research demonstrated that MBCT can effectively alleviate the stress, anxiety and depression of the family caregivers of people with dementia (Kor et al., 2021). The application of MBCT is in its infancy in China, current limited Chinese studies show that MBCT can relieve anxiety, depression and other adverse emotions in various populations, including chronic heart failure patients, pregnant women, as well as breast cancer patients and improve their coping methods (Zhao, 2019; Wang et al., 2020; Zhao et al., 2020).

Our research focus on the mental health of the main caregivers of children with allergic rhinitis, the caregivers were given an 8-week online Mindfulness-Based Cognitive Therapy (MBCT). The purpose of our study was to implement intervention programs in order to explore the impact of the online MBCT program on care burden, mental status and mindfulness level of the main caregivers of children with allergic rhinitis.

To date, this is the first quasi-experimental concurrent controlled trail to examine the effects of a modified online MBCT intervention on the caregivers of children with allergic rhinitis. Meanwhile, this is the first clinical practice in China to intervene patient caregivers with a MBCT program. We compared with a previous study of the modified MBCT program on dementia caregivers with attrition rate of 8.9% (Kor et al., 2021), the modified online MBCT protocol in this study resulted in a lower attrition rate of 5%. The caregivers of allergic rhinitis children demonstrated a significant improvement in the caregiver burden and mindfulness level, but the effect lasted no more than a month after the intervention. In addition, depression level of the caregivers improved significantly, and the effect could last until the 1-month follow-up.

Primarily, once diagnosed with allergic rhinitis, children need to endure long-term medication, frequent medical visits, physical discomfort, and complications. Meanwhile, the caregivers of the children have to withstand great caregiver burden, either from the physical, psychological, emotional, or from other aspects. The occurrence of children’s disease makes the caregivers be under psychological stress, and this stress response and coping style will inevitably affect the level of care they provided. We are able to anticipate that a program which can reduce the caregiver burden of the caregivers in children with allergic rhinitis, will have positive effect on promoting the physical and mental health of the children with allergic rhinitis, as well as their caregivers. In our study, the traditional MBCT therapy (Segal et al., 2013) was modified in accordance with the specific need of the caregivers, and performed in a relatively safe environment the caregivers had chosen. The caregivers were encouraged to discuss their care-giving experiences that increase caregiver burden, and their coping mechanisms were enhanced through mindfulness practice. The result of our study was consistent with the previous study conducted by Wood et al. (2015), the modified MBCT is appeared to be an effective intervention for caregiver burden reduction of chronic disease patients’ caregivers.

Next, it is clear that MBCT is an effective treatment for recurrent depression, anxiety and other problems which can cause stress. As the number of depression recurrence increases, there is a growing “intrinsic susceptibility,” an overreaction to adverse emotion, which manifests itself in two ways: experiential avoidance, an effort to avoid unwanted experiences; rumination, to solve the problem of mind in a exhausted way. Therein, rumination involves a repetitive and passive focus on the causes, consequences and symptoms of negative care-giving experiences, is an important mediator of depression and anxiety in patient caregivers (Nolen-Hoeksema, 2000; Slavish, 2015). The modified MBCT program aims to eliminate the mediator, helps the caregivers disengage from their ruminative thoughts through mindfulness practice, and works around coping “intrinsic susceptibility.” It focuses on the participants building new relationships with individual negative care-giving experiences, rather than changing the experiences themselves, thus, the caregivers will respond more skillfully to these negative care-giving experiences and mental process. Combining the observation of our study and a previous study (Kor et al., 2021), it can deduce that the modified MBCT therapy can effectively reduce anxiety and depression in the caregivers of patients with chronic disease.

Moreover, our study monitored mindfulness level of the participants for almost 3 months, before and after the intervention, and at the 1-month follow-up. The results showed that the modified MBCT therapy can significantly improve mindfulness level in the caregivers of patients with chronic disease, which is consistent with the results of a previous study (Kor et al., 2021). Furthermore, to explore the factors which may influence the effects of MBCT therapy, future research can make a more detailed analysis of the differences between the participants who benefit more and the participants with no apparent effects.

Finally, in 2019, a study from Birtwell et al. (2019) showed that improvement in a participant’s mindfulness level resulted not only from formal mindfulness practice, but also from informal mindfulness practice. The informal mindfulness practice refer to mindfulness practice which has been incorporated into the daily activities of the participants, such as mindful walking and mindful eating. Formal practice and informal practice of mindfulness reinforce and complement each other, and foster the same kind of mindfulness. Formal practice of mindfulness is like sharpening a knife. Informal practice of mindfulness in daily activities is like using a life. Along with the learning process, we need to understand how to diffuse the gentle awareness fostered by formal practice of mindfulness into our daily lives, in order to be better aware of and response to adverse care-giving experiences. As Dr. Kabat-Zinn has said, “the real Session 8 is the rest of our lives” (Segal et al., 2013), we should not regard the last session as the ending, but rather as the starting of a broader and ongoing journey of mindfulness. In our study, we did not document the informal practice of mindfulness of the caregivers and how they incorporated mindfulness practice into their care-giving routines. Future research can record and analyze the influence of informal practice mindfulness practice on the MBCT intervention effect, expand the scope of MBCT intervention, thereby, help the caregivers maximize the use of mindfulness in the process of caring for patients with chronic diseases and improve their care-giving experiences.

In summary, the modified online MBCT program helps to equip the main caregivers of children with allergic rhinitis with the skills of mindfulness to improve their care-giving experiences. The 8 week intervention appears to be effective at reducing their care-giving burden, relieving their anxiety and depression level, and improving their mindfulness level. Comparing to the traditional MBCT therapy, the modified online MBCT program is more convenient and less restricted to the site. In addition, it has strong operability, and good intervention effect, which is suitable for clinical practice. It is recommended that future research be conducted in different medical settings, recruit participants with a wider range of sociodemographic backgrounds, and investigate more psychological indicators to further verify the efficacy.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving humans were approved by Ethics Committee of Zhongnan Hospital of Wuhan University. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

XY: Conceptualization, Formal analysis, Methodology, Project administration, Software, Validation, Writing – original draft, Writing – review & editing. ZX: Data curation, Formal analysis, Software, Visualization, Writing – review & editing. HS: Conceptualization, Investigation, Methodology, Supervision, Validation, Writing – review & editing. JL: Formal analysis, Resources, Validation, Writing – review & editing. YG: Conceptualization, Investigation, Methodology, Validation, Writing – review & editing. JZ: Data curation, Formal Analysis, Software, Visualization, Writing – review & editing. XD: Formal Analysis, Resources, Validation, Writing – review & editing.