Effects of Cognitively Based Compassion Training in the outskirts: A mixed study

Abstract Objective: to analyze the effects of Cognitively Based Compassion Training (CBCT®) among people in situations of social vulnerability. Method: a mixed, sequential and transformative study with the same QUAL→QUAN weight. Focus Groups were applied at the beginning (n=24) and three months (n=11) after CBCT®, to understand the participants’ knowledge about emotions, (self)care and stress situations. Content analysis was performed in the WebQDA software. The participants (n=65) were randomized into control (n=31) and intervention (n=34) to assess self-compassion, perceived stress, and positive and negative affects at three time moments. The mixed factorial ANOVA analysis considered within-participants (time) and between-participants (place and group) factors. Results: mean age (37), female gender (88%), single (51%) and black-skinned people (77%). The following thematic categories emerged before the course: “Reducing others’ suffering as a bridge to conscious self-care” and “Social vulnerability as a potentiator of low emotional literacy”. Subsequently, self-compassion and awareness of the mental states for social activism. The quantitative analysis showed a significant increase in self-compassion within-participants (p=0.003); group factor (p<0.001); perceived stress reduction (p=0.013); negative affects group factor (p=0.005); and increase in positive affects (p<0.001) within-participants. Conclusion: CBCT®️ exerted a positive effect on individual well-being and a positive impact on community engagement to promote social well-being in the outskirts. Brazilian Registry of Clinical Trials (RBR-3w744z.) in April 2019.


Introduction
From the perspective of social determination, the existence of an intimate relationship between health and society is undeniable. Thus, all analyses of the health-disease-care process must necessarily consider the contradictions and social vulnerabilities that underlie the health problems and the way in which people with different social backgrounds access professional, popular, and informal care resources, including self-care (1)(2) .
Social vulnerability is an interdisciplinary expression that refers to the sense of guaranteeing citizenship and to the fragility of social well-being, determined by a combination of sociopolitical and cultural factors that interfere with access to goods and resources to ensure the right to life with dignity (1) . Issues such as housing, income, usual sources of care, social networks, education, culture, individual and social expectations for the future are important social determinants of health. However, it is also necessary to attribute to the sphere of social (re)production the determination of the strains and strengthening instances of the health-disease-care process experienced by people, which can result in health problems (2)(3) .
With the understanding that care is inherent to human beings as a starting point, it can be admitted that social vulnerability reveals a complex process of (not) taking care (of oneself). In contexts of difficulties or lack of access to human rights, abandonment of care can represent humanity's susceptibility to harms, distress or fatigue and finitude. Not taking care (of oneself) refers to the fragility and insecurity inherent to human beings, which can be manifested in the ontological, ethical, political, natural, cultural and social dimensions (4)(5) .
In order to expand the scope of interventions with an individual and specialized therapeutic approach, new models for promoting the well-being of populations with ethnocultural specificities are suggested (6)(7) . In the field of Psychology, well-being comprises a complex and positive dimension of health that integrates cognition and affection.
It is an ecological concept that comes from a broad system of intrinsic and extrinsic factors that influence the way or quality in which people lead their lives (8)(9) .
Several studies have shown that well-being can act as a preventive factor against diseases. The presence of happiness and satisfaction with life implied a lower risk of mortality in healthy populations (9)(10)(11)(12)(13) . These results can be enhanced by training the mind in compassion (14) . Compassion is the sense of concern that arises when a person is faced with another's suffering and the motivation to alleviate it.
It is understanding the emotional state of other people and taking care of those who suffer. It also means promoting well-being in order to develop altruistic behaviors. When it is focused on the individual, it becomes self-compassion (15)(16)(17)(18) .
Recent studies indicate that training the brain in compassion through meditative practices results in changes in the body's biochemical responses, such as a reduction in the levels of the inflammatory stress hormones and an increase in hormones linked to happiness (17,(19)(20)(21)(22)(23) . This type of mind training expands behavioral domains, develops altruistic skills, and changes neural responses to suffering, which provides diverse evidence of neuroplasticity in the circuit underlying compassion and altruism (24)(25)(26)(27) .
There are numerous compassion-based interventions.
Programs employed as an effective emotion regulation strategy outside the traditional meditative context are associated with the endogenous production of positive affect, stimulating resilience to the suffering of others in the general population while promoting emotional connection and pro-sociality (19)(20)(21)(24)(25)(26)(27)(28) .
Cognitively Based Compassion Training (CBCT ® ) is a secular program for training the mind in compassion with proven effectiveness in different groups; mostly, adult university students or specific groups in treatment of diseases. However, it is necessary to expand the proof of effectiveness with populations in social vulnerability situations. The peripheral communities of large urban centers, "the outskirts", are part of this scope, and it is with them that we will develop this study (28)(29) . The objective was to analyze the effects of Cognitively Based Compassion Training (CBCT ® ) among people in situations of social vulnerability.
It is understood that the current research brings with it theoretical-practical contributions due to its social relevance, innovation and advancement in scientific knowledge. Its contribution is also recognized so that people in situations of social vulnerability have access to practices that promote individual and collective well-being.

Study design
This is a mixed-methods research study of the sequential transformative type and with the same weight between the QUAL→QUANT approaches. Data combination was performed through integration and occurred in the results and discussion. Choice of the transformative method is justified from the perspective of Paulo Freire's epistemological theory, associated with the main researcher's previous engagement in the communities participating in the study, in the direction of social justice and appreciation of the peripheral culture (30)(31)(32)(33) .   In the quantitative approach, a randomized and controlled study compared the benefits of the intervention on self-compassion, perceived stress, and positive and negative affects to the regular activities of Civil Society Organizations (CSOs). The dependent variables were the following: self-compassion, perceived stress, positive affects and negative affects. The independent variables were locus and group. A design with analysis between and among participants was used: 2 (Locus: CSOs vs. community) X 2 (Group: Intervention vs. Control) X 3 (Moment: T1 vs. T2 vs. T3). For this article, we used the results of all the aforementioned methods, except IIs in an integrated way. This approach focuses on the praxis, looking at and reflecting on the practice, considering ethics and well-grounded feelings (32)(33) .

Study scenario
The study was carried out with assisted people and volunteers from two CSOs, in the region of Parelheiros, municipality of São Paulo, SP, Brazil. These are institutions that work on human rights and are located in peripheral areas. In partnership with five communities, they cocreated the Center for Excellence in Early Childhood (Centro de Excelência em Primeira Infância, CEPI). During creation, difficulties were identified by the collective, such as: lack of focus, self-demand, and signs and symptoms of anxiety and stress for a more effective performance and contribution to well-being. During CEPI planning, the care for excellence was divided into dimensions and the contribution of meditative practices to the dimension of caring for the team was proposed to the researcher.   (34) A five-point Likert scale (from 1 = Almost never to 5 = Almost always) with 26 items assessing self-compassion about how people relate to themselves in difficult times. The items are divided into six subscales: self-kindness, severe self-criticism, sense of humanity, isolation, mindfulness, and over-identification. The overall score is calculated using the total of the subscales' mean values after reversing the items from the negative subscales: 1, 2, 4, 6, 8, 11, 13, 16, 18, 20, 21, 24 and 25. The higher the score, the greater the self-compassion.

Self-Compassion Scale
Perceived Stress Scale (PSS) (35) A five-point Likert scale (from 0 = Never to 4 = Very often) with 10 items assessing the frequency of feelings and thoughts related to events and situations that occurred in the last month. Items 4,5,7 and 8 are inversely scored and added to all the items to calculate the total score, which varies from 0 to 40. A higher scores indicate more stress.

PANAS-X (Positive Affect Negative Affect Scale)-
Adapted (36) A five-point Likert scale (from 0 = Very little or not at all to 5 = Excessively) with 60 items assessing Positive Affects: basic positive affects, including joviality, selfconfidence and attention; Negative Affects: basic negative affect, including fear, hostility, guilt and sadness; as well as other affective states, including shyness, fatigue, serenity and surprise.
The scores for each dimension are calculated by adding up the ratings of all emotions included in each level and dividing the total by the number of emotions in each dimension, so that the scores vary from 1 to 5.
In the sum, higher scores for Positive Affects indicate subjective well-being, disposition and enthusiasm and, for Negative Affects, they signal dissatisfaction with life, displeasure and subjective malaise.

Quantitative approach
The participants' sociodemographic-emotional profile was obtained using a self-administered questionnaire and scales in Google Forms ® format. Individuals with difficulties reading and using computers were offered support. Two previously trained Nursing students conducted data collection with the researcher.

Qualitative approach
All individuals were invited to participate in the initial FG (T1) and only those in the intervention group, for T3. Class 1 (n=11), Class 2 (n=13) at the pre-randomization phase, Class 1 (n=10) and Class 2 (n= 6), 3 months after the intervention. The FGs lasted two hours, were audio-recorded, transcribed (without the participants' review) and conducted by a female interviewer, author of this paper, following a pre-prepared script. There

Script for guiding questions
T1 FG -Meeting to discuss the research object (37) . How are the effects of stress on you? What is self-compassion and self-care? T2 Interview -Conversation with a purpose (38)  analysis and data synthesis (39) .

Intervention
CBCT ® is a secular program of compassion meditation based on cognition and develops cultivation of compassion through meditative exercises (28,40) . It proposes to the participants the development of stability regarding attention and awareness of the nature of the mind  The meetings were held in the CSO space and lasted 2 hours, with weekly frequency and for nine meetings.
They took place in a conversation circle format with projections, dynamics, texts for reading and videos for appropriation and dialog about the content and practices.
The participants received a handout about the course and audios for practicing the meditations and were encouraged to write about experiences from the weekly practices. A social networking group was created for communication. All were invited to practice meditations outside the meeting hours for a mean of 15 minutes a day. The meetings were audio-recorded to ensure the content applied and fidelity to the CBCT ® manual.

The instructor is certified by the Emory University
Center for Contemplative Science and Compassion-Based Ethics, with long-standing experience in meditative practices and program teaching.
The control group remained in the regular activities offered by the CSOs, physical activities, art workshops, reading, cooking, permaculture and conversation circles.
At the end of the study, CBCT ® was offered to the entire control group.

Results
The results point out to QUAL→QUAN analyses in complementarity and revealed complex experiences, allowing other researchers to apply the model in different population groups.
To meet the objectives of this study, the results were divided into two main parts. In the first one, the sample

Self-compassion
The self-compassion variable presented normal distribution at the three levels (T1, T2 and T3). Presence of only one outlier at T2 was observed in the community group, choosing to keep it in the analysis considering that ANOVA is robust in relation to small violations.
The homogeneity assumption was complied with, but homoscedasticity was violated. Therefore, for the withinsubject effects, the Greenhouse-Geisser statistic was reported.
A significant difference was observed for the within-

Negative affects
The variable presented normal distribution at the three levels (T1, T2 and T3), there was a violation of normality at T2 in the CSO and intervention groups.
However, these were not significant violations, opting for not transforming the variable. Presence of only five outliers was observed at T2, which were maintained in the analysis, as their removal did not imply changes in the results. Compliance with the homogeneity and homoscedasticity assumptions was observed. A mixed ANOVA 2 analysis was performed (Locus: CSO vs. community) X 2 (Group: intervention vs. control) X 3 (Negative Affects: T1 vs. T2 vs. T3).
There was a significant difference in the within-

Positive affects
This variable presented a normal distribution violation at the T1 level for the community, intervention and control subgroups; and at the T2 level for the control group.
Presence of eight outliers was observed between T2 and T3, which were removed. After its removal, the variable presented normal distribution across the three levels. (Pega-pega)

Discussion
The hypothesis of this study was that the CBCT ® applied in the "outskirts" improves self-compassion, perceived stress, the perception of feelings and emotions, and the individual and social well-being of CSO assisted people and volunteers.
As the first study to investigate the effects of the A number of studies show that self-compassion is positively related to social ties. The compassion we direct to ourselves is the one we offer to other people (18,44) . The connection with the other's suffering drives the group to a loving dialog with the other or with oneself and allows practical reflections for more resilient states (18) . The greater the self-compassion, the greater the compassion for the others and the greater the well-being and social transformation (45)(46) .
In relation to the effect on the perception of situations as stressful, there was a significant reduction over time in both groups, with a greater reduction between the initial and final moments of the course in the intervention group. The similar perception for everybody suggests that mental distress is common to all beings (45)(46) . The connection between people who are part of the same community and share living spaces can contribute to the reduction of social stress (47) . Another interpretation is that social vulnerability sustains the effects of stress for a longer period of time, as well as physical and psychological symptoms (48) .
A number of studies show that the perception of stress is not necessarily something negative, but a perception for self-regulation. It is worth remembering that the PSS scale asks the reader for an assessment of the last month, which contributes to the understanding that social vulnerability can enhance low emotional literacy. It is necessary to understand both the nature of the social situation and the means to transform realities, which takes time (49) .
Negative affect had a significant reduction over time for the CBCT ® group from the initial to the final phase of the course, although with an increase between the end of the course and the measurement after three months.
Recognition of the modules in everyday life appears in the participants' reports, suggesting a challenging path to self-compassion and individual transformation. Structured inequalities, such as racism, misogyny and homophobia, are like heart diseases that take longer to be discovered and/or treated (49)(50)(51) . This requires identifying the suffering itself, its perception and an approach to unpleasant experiences (52) ; with compassionate acceptance to recognize suffering in its raw state, relating to it in a more conscious way and allowing the support of conscious and non-judgmental attention (27,50) .

A significant increase in positive affect was observed
for the intervention group, regardless of whether the participants belonged to the category of community or volunteer people. In relation to time, there was a reduction from the beginning to the end of the course and an increase in the period between the end and after three months of intervention. Increased long-term subjective well-being was reported and associated with self-care, self-compassion and empathy, as suggested by a number of studies (10,44) . The purpose of the practice is not to increase positive affects or reduce negative ones, but to live the present moment, meeting the sensation that arises without creating attachment or aversion and perceiving the experience as it is. A number of studies in socially vulnerable populations show an improvement in emotional regulation and social relationships (23,45) .
The narratives revealed more conscious and more self-compassionate self-observation, as well as insights into changing attitudes and behaviors. The empowerment of being a social activist was noticed, as well as the connection with oneself and with others as a motivation for more people to experience the same situation with greater resilience and without losing focus on self-care, as suggested in a previous study (23) . In addition to that, mind training expands behavioral domains, affecting social behavior outside the training context. According to Freire, this is a process of awareness raising, development of awareness for critical reflection, which includes historicalcultural conditioning and transforms reality (32)(33)53) .
Finally, it is noted that there are significant relationships between the practice of meditation in compassion and situations of social vulnerability, namely: being a black-skinned woman, peripheral and volunteering.
perception of emotional self-regulation, clarity of one's inner values and life purpose. This is explicit in what the literature reports on intersectionality, on the pillars for the promotion of well-being and on the courage to love (11,49) .
These correlations must be interpreted with care due to the specific scenario. It is important to highlight some study limitations regarding the small number of the sample and for being the first study on CBCT ® and conducted in a South American cultural context.
It is worth noting the fact that some participants