This Special Issue begins with a target article, “Mindfulness for Global Public Health: Critical Analysis and Agenda” (Oman, 2025), which has initiated a scholarly discussion on integrating mindfulness into public health theory and practice. In that target article, the present author systematically compared the mindfulness and public health fields on 14 relevant dimensions or “axes,” such as “prevention orientation” and “cultural adaptation common,” seeking to show pathways toward how mindfulness might be integrated into public health. As published in this issue, a distinguished international and interdisciplinary group of scholars has now responded with numerous insightful commentaries. This reply builds on the received commentaries, sketching implications and pathways forward, culminating in a systematic framework for implementation. The editors of Mindfulness have signaled this journal’s openness to continued discussion on the relevance of mindfulness to public health (Medvedev & Krägeloh, 2025). Therefore, the present reply is intended not as a conclusion, but as a bridge to additional conversation, research, and action.
In what follows, responses are grouped largely according to topic, under separate headings, arranged in an order that is most convenient for exposition. Space limitations prevent addressing all significant and generative observations by commentators. But I hope that the present reply will help engage the readers, and all the commentators, in carrying forward this important conversation, and the beneficial action that we hope it will enable.
This commentary contains two major sections, each divided into multiple subsections. The first major section emphasizes questions and themes most central to supporting community resilience through mindfulness and contemplative practices in public health efforts. Its subsections build on each other, and address issues including safety, foundational causality conceptions at individual and collective levels, religious and cultural adaptations, partnership and administration, branding, and implementation. The last subsection acknowledges numerous ways that commentators have already begun pursuing the field’s needed agenda. That subsection also begins addressing a gap in defining attentional health. Finally, the present reply culminates by presenting, in its last major section, a step-by step implementation framework for appropriately integrating meditation or mindfulness into public health. Readers interested in implementation tools and takeaways could skip ahead to that section, titled “Step-by-Step Framework for Integrating Contemplative Practices into Public Health.”
Groundwork for Appropriate Implementation
Are mindfulness, meditation, and other contemplative practices ready for implementation in public health? Regardless of potential benefits and drawbacks, they have already been integrated into public health efforts for many years—if one uses a broad interpretation of “organized” when applying classical definitions of public health as comprising “organized efforts and informed choices of society, organizations, public and private, communities and individuals” (Table 1 in Oman, 2025). A more sensible question, then, is how they can be more fully and effectively integrated into public health, and how any flawed forms of integration can be identified and repaired. Over time, many health and human service fields, including public health, have evolved and improved through a combination of governmental (“top-down”) and community-based (“bottom-up”) initiatives (Fullan, 1994; Homsy et al., 2019; Nagorcka-Smith et al., 2022; Sabatier, 1986; Susser, 1995). The mindfulness field, too, has been developing in this manner (see, for example, Bristow, 2019; Hechanova et al., 2015; Tobias Mortlock et al., 2025). Therefore, the present section foregrounds and replies to issues deemed important for the long-term mutual support or synergy of community-led and institutional initiatives to use mindful and meditative practices for community health.
Definitions
Of course, a recurring challenge is to remain clear about what we are discussing. Multiple commentators noted—and I agree—that many extremely diverse phenomena have been labeled with terms such as “mindfulness” and “meditation” (Farias, 2025; Sedlmeier, 2025). Therefore, a local effort at public health integration—such as might emerge from applying the implementation framework presented later in this reply—should carefully appraise the merits of any program proposed for health promotion inclusion. Civic and public health leaders should not assume that any program that self-brands as “mindfulness” is delivering something worthwhile, even as they would not assume (one may hope) that any program self-branded as “miracle cure” does in fact deliver a miracle cure.
In the target article and in this reply, most mentions of mindfulness are to be understood in the context of either (i) prototypical mindfulness-based programs, such as Mindfulness-Based Stress Reduction (MBSR), or (ii) what the target article called Buddhist and “non-Buddhist contemplative practices… viewed as analogues to modernized mindfulness programs” that are similar or comparable in certain respects, thus reflecting a “coherent resemblance” (Oman, 2025). The most relevant analogues are usually (1) other systems of traditional contemplative practice that involve a practice of sitting meditation (Oman, 2021), (2) their careful contemporary adaptations such as have been studied and described by others, including present commentators (e.g., Bringmann et al., 2021; Knabb & Vazquez, 2025; Waelde, 2022), or (3) the more “portable” yet comparatively well-researched, evidence-based, and widely cross-culturally rooted practice of frequent repetition of a holy name or mantram throughout the day (Oman & Driskill, 2003; Oman et al., 2022; Oman, 2024b).
Moderators of Effects
Sedlmeier (2025) has expressed concern about the numerous moderators of effects from mindfulness programs that have been identified, as well as the experience of adverse effects by some individuals. Other commentators have also noted the existence of such effect moderators (e.g., Buric et al., 2022; Farias, 2025). Preventing and addressing adverse effects are very important. This raises the question: Does the existence of moderation pose a major obstacle to integration?
Public health addresses many protective and risk factors that are non-uniform in their individual effects. As noted in the target article, best practices in public health involve cultural and other forms of adaptation. Once moderators are identified or suspected, they can be mitigated or managed in various ways, such as developing tailored programs, or providing individual advisories or referrals to alternatives. And as Sedlmeier (2025) suggested, for such management, better theory could be helpful for rapidly constructing individual advisories and program adaptations. Yet for any program and for any matching procedure, some individual response variation will always likely remain. Need it be an obstacle to public health integration?
Consider the analogous task of promoting physical activity, which has long been incorporated into public health. Physical activity exists in a myriad of forms, as does physical exercise, distinguishable from physical activity as being “planned, structured, and repetitive” (Caspersen et al., 1985, p. 126). Many factors may moderate the effects of specific forms of physical activity on mental and physical health outcomes (e.g., White et al., 2024). But this has not proven an obstacle to multi-level and cross-sectoral public health interventions to support physical activity, such as ensuring adequate pedestrian infrastructure, and encouraging physical activity in schools (e.g., Hills et al., 2015; Omura et al., 2020). From a public health perspective, a primary strategic purpose of such initiatives is not so much to protect specific individuals, as to shift overall population health metrics (Rose, 1985).
Similarly, loneliness has been recognized as a major public health issue (Office of the Surgeon General, 2023). Factors such as age have been identified as moderators of effects from loneliness interventions and in vivo social connections (Beckers et al., 2022; Carmichael et al., 2015; Hogan et al., 2002). But neither such moderation nor remaining individual variation was flagged as a major obstacle in a recent analysis on how the US public health system could work to address and prevent loneliness (Crowe et al., 2024).
Interventions for Children
Importantly, Farias (2025) questioned the suitability of meditation interventions for children, noting the failure of a recent large-scale UK school-based trial (Kuyken et al., 2022), and the rarity of historical accounts of such practices for children. Such cross-cultural rarity should indeed be cause for reflection and questioning: Has there been a historical global consensus in appraising sitting meditation as developmentally premature for children? This prompts further inquiry: How do current representatives of such traditional cultures explain their stances toward meditation by children? And how do such stances tally with contemporary developmental theories, findings, and approaches (e.g., Roeser et al., 2023)? Yet even if sustained meditative practice is contraindicated for children, a related question is whether children or adolescents may benefit from a modicum of culturally appropriate contemplative instruction that plants a seed, giving them skills that they can call upon in times of distress in later life. In some Buddhist cultures, brief coming-of-age monastic ordinations seem to serve an analogous seed-planting function (Whittaker, 2002).
Mindfulness-related work in schools might also benefit from considering contemplative practices beyond sitting meditation that are also widely practiced across cultures. Roeser et al. (2023) discussed the integration into educational programming of contemplation-related virtues such as compassion. Also meriting consideration is mindfulness-supportive practices such as the “portable” repetition—at opportunities throughout the day, rather than during a dedicated sitting practice—of a mantram or holy name (Oman et al., 2022; Oman, 2024b). Portable mantram repetition does not include the same self-regulatory demands as sitting meditation, arguably rendering it developmentally compatible with substantially younger age groups. Moreover, repeating a mantram or holy name, on occasions of felt need throughout the day, appears to have been widely regarded across cultures as suitable for children. For example, Mahatma Gandhi (1927) reported that, to help him manage his childhood fears, his nurse introduced him to “Ramanama” (mantram repetition) at an early age, and that “it is due to the seed sown by that good woman… that today Ramanama is an infallible remedy for me” (p. 27). Ensuring culturally sensitive implementation of children’s mantram repetition programs in pluralistic settings would require careful structuring, but should be feasible—especially if adults are persuaded that such programs can plant age-appropriate protective “seeds” (see Appendix for further discussion of implementation needs and feasibility for children).
Safety Assurance and Ethics
The potential for adverse health events caused by mindfulness interventions was extensively discussed by Farias (2025), and also noted by Berryman (2025). They have appropriately highlighted an issue that must be taken seriously in public health integrations. Although reviews of adverse health events in meditation interventions had already appeared nearly two decades ago (e.g., Arias et al., 2006), it is only recently, as Farias noted, that the topic has received sustained attention in the mindfulness literature. To address such concerns, the present section focuses first on risks of adverse health events as emphasized by Farias (2025) and the larger mindfulness literature, responding in a later subsection to concerns by Berryman (2025) about risks of adverse moral effects.
Concerns to avoid intervention-induced adverse effects on physical and mental health or psychological well-being converge with one of the widely recognized core functions of public health, called “assurance,” sometimes described as assuring that “necessary services are provided to reach agreed upon goals” (Institute of Medicine, 1988, pp. 43, 45). Similarly, the World Health Organization (2003) refers to “quality assurance” (p. 23) and “health protection” (p. 24), noting that “quality is subject to statutory inspection in most countries” (p. 24). These functions are commonly understood as involving the provision of safe medical care (patient safety), but also extend to other societal concerns that include occupational safety, environmental safety, traffic safety, food safety, and other forms of consumer safety. In the USA, the corresponding regulatory agencies range from the Occupational Safety and Health Administration (OSHA), to the Food and Drug Administration (FDA), to the Consumer Product Safety Commission (CPSC). Importantly, socially “agreed upon” safety goals may vary between societal sectors. For example, driving safety standards appropriate for residential neighborhoods would be deemed overly intrusive for auto racing events. Similarly, different exercise safety procedures may be recognized as appropriate for college intramural sports versus cardiovascular rehabilitation programs. Legally mandated (and in that sense socially agreed upon) safety standards may sometimes also differ between cultures (e.g., Atchley et al., 2014; Johnson & Covello, 1987; Raheem & Hinze, 2014).
Thus, even as mindfulness programs vary between social sectors in their specific touted goals, sector-specific safety procedures may also often be necessary and appropriate for mindfulness and meditation programs. In the religious sector, Schlosser et al. (2019, p. 13) noted that many traditional accounts draw a clear distinction between “merely negative experiences” that provide no lasting benefit, versus experiences that are “difficult, but nonetheless integral parts of the meditative practice or essential for receiving its potential benefits,” which may include existential flourishing (or even spiritual salvation). Schlosser et al. (2019) noted that contemporary science lacks tools to distinguish between these two types of experiences. Moreover, attempts to legally forbid religious organizations from teaching contemplative practices that risk moderate hedonic discomfort would be widely, and with much justice, perceived as an infringement on freedom of religion. But beyond the religious sector, how should mindfulness and contemplative safety be understood, implemented, and regulated?
Some practical guidance has begun to emerge. For example, regarding mindfulness interventions, perhaps especially with reference to clinical settings—though the sectoral scope of their intent is somewhat unclear—Baer et al. (2019) reviewed how harm is understood in related health and well-being fields, including psychotherapy, pharmacotherapy, and physical exercise. These fields all recognize potential risk or protective influence from three classes of factors related to (i) treatments, (ii) patients, and (iii) clinicians. Baer et al. (2019) recommended that, before a mindfulness-based program begins, a pre-program orientation and informed consent process should “explain to potential participants… what difficulties might arise, how these can be managed, and whether the potential benefits are likely to outweigh the difficulties” (p. 110), and that interventions should follow “well considered exclusion criteria” (p. 110). Similarly, Van Dam et al. (2018) have suggested that a key reference point is an intervention’s “‘product labeling,’ ‘package insert,’ ‘marketing or advertising’” (p. 47). Additional recommendations by Baer et al. (2019) include non-pressuring teaching styles and systematic monitoring.
As a reference point and spur to further development, a multi-sector review of extant mindfulness and meditation intervention safety protocols could be quite useful. Also needed is ongoing attention to ensuring safe multisectoral equivalents of the third of the three factors noted by Baer et al. (2019), the “clinician” factor, perhaps generalizable across sectors as akin to an “instructor” or “provider” factor. In this connection, the target article’s discussion of administrative needs and adaptation (Axis A11) noted that validated train-the-trainer procedures have been developed for prototypical mindfulness programs (e.g., MBSR), as well as the Mantram Repetition Program (Buttner et al., 2016). But respect for cultural diversity may sometimes suggest or require offering an “ensemble of functionally analogous alternatives” (Oman, 2025), including mindfulness analogues derived from single religious traditions. For such analogues, similarly validated train-the-trainer procedures, ideally credential-awarding and explicitly addressing adverse events, could be extremely helpful for safe intervention delivery. Some manualization of a Christian analogue has been undertaken by Knabb (2021), although train-the-trainer research for most contemplative traditions appears lacking and is needed.
In addition, the exploration by Baer et al. (2019) of parallels with physical exercise can remind us of the importance of disaggregating non-severe and severe adverse events, and avoiding excessive concept creep, the tendency to broaden categories “such that existing category labels begin to encompass a wider and more diluted range of exemplars” (Harper et al., 2023, p. 319; see also Haslam et al., 2020). Physical exercise scholars Cook et al. (1997, p. 999) noted that “the experience of muscle pain that occurs naturally during intense exercise in healthy people is widely recognized” (p. 999), and is seldom medicalized. Rather, exercise-induced pain, for which O’Malley et al. (2024) provide four distinguishing conceptual and phenomenal characteristics, “affects individuals across the entire spectrum of exercisers, from sedentary individuals to elite athletes [and is] salient, intense, and unpleasant, but is also both transient and non-damaging … [yet] has previously been conflated with other pain types and taxonomies” (p. 1446). Some adverse meditative events, like some exercise events, can be extremely harmful (Farias et al., 2020). But do meditative interventions give rise to unpleasant experiences that—like ordinary “exercise-induced pain”—are transient and unharmful, but can confusingly be conflated with more serious adverse events?
Few if any interventions, even placebo interventions, are entirely free from the possibility of measured adverse events. For example, as summarized by Colloca and Barsky (2020) in the New England Journal of Medicine, “up to 19% of adults and 26% of elderly persons taking placebos report side effects [and] as many as one quarter of patients receiving placebo in clinical trials discontinue it because of side effects” (p. 554). This range is actually slightly higher than the “8 to 22%” rate of adverse effects cited by Farias (2025), underscoring the importance of research procedures and practice protocols that coherently disaggregate adverse events by level of severity.
In sum, safety assurance for mindfulness and meditative interventions is important, as noted by commentators—yet a multisectoral public health perspective recognizes that its societal bases and implementation logistics may vary between sectors and perhaps cultures. Some practical safety guidance has begun to emerge in the clinical sector (e.g., Baer et al., 2019), but tailored adaptations and implementations of safety guidance are desirable, and may ultimately be necessary, for each sector. Such sectorally attuned guidance should also be reviewed, and refined over time as research progresses in understanding the sources and types of adverse events, and their implications for maintaining optimal safety in each sector.
Indeterminate Individual Causal Effect Pathways
Sedlmeier’s commentary posed the question “why should mindfulness practices work?” and expressed concern that “theoretical models for mindfulness practices are… still quite heterogeneous.” This theoretical heterogeneity—which cannot be dissipated simply by asserting a theoretical preference—Sedlmeier (2025) saw as jeopardizing public health integration “in the long run.” Theories about why interventions work have typically sought to characterize factors or describe processes that causally mediate effects from interventions—their so-called “mechanisms” (see review by Tan, 2025; see Ross, 2021 on why “mechanism” can be a misleading metaphor even in biology). Such causal mediation theories have been called “program theory” by West and Aiken (1997), and were called “impact theory” in the target article. Sedlmeier (2025) was not fully explicit in articulating what he saw as the functional uses of such mediation theories, and why theoretical heterogeneity might present long-run obstacles to public health integration. However, at least four potential uses of individual-level program impact theories seem particularly relevant to public health integration (these uses converge strongly with clinical uses articulated by Kazdin, 2007). The public health uses of program impact theory include:
(i)
understanding and documenting an intervention’s specific causal efficacy (as distinct from any common but non-specific processes, such as social support in a group-delivered intervention), thereby warranting the intervention as providing added value to health promotion and practice;
(ii)
informing research to determine who is likely to benefit most from the intervention (moderator effects), thereby helping guide priorities for social and individual allocation;
(iii)
informing efforts to ensure that interventions are safe at the individual level (see next section regarding population level safety); and
(iv)
identifying core intervention elements for guiding efforts to adapt the intervention to specific populations, or to identify relevant intervention analogues (i.e., overall functional substitutes), such as contemplative practices derived from indigenous cultural or religious traditions.
Conduct of these tasks—documenting specific efficacy, determining allocation priorities, ensuring safety, and choosing adaptations or analogues—has to some degree been proceeding already, often in a somewhat ad hoc fashion, in relation to the delivery in various settings of mindfulness and other meditative programs. But I agree with the advocacy by Sedlmeier (2025) of further work on developing and refining impact theories, especially theories that support wisely and effectively addressing practical tasks of public benefit, such as the four just listed. Sedlmeier’s commentary offers a helpful brief overview of several theoretical streams that have influenced theorizing to date on causal effects from meditative programs. Whether or not there eventually emerges what Sedlmeier called a “general theory” of meditation, I suspect the most pressing immediate need for practical application may be mid-level impact theories that support skillfully conducting the four types of tasks just noted.
Yet solidly replicated empirical evidence of benefit—including evidence about generalizability across different groups—may warrant some degree of public health integration of mindfulness and meditative interventions even without impact theory breakthroughs. Consider, for example, the precedent of aspirin.
Aspirin and the Primacy of Practical Benefit
Aspirin illustrates that well-attested practical benefits can be compelling: Well before the discovery by John Vane (1971) of its main physiological “mechanisms,” aspirin was “long the most widely used medicinal drug in the world” (Collier, 2024, p. 116). For generations, aspirin had been widely used in medicine and public health. For example, in the late 1950s, Kramer (1958), in describing large-volume prescription items being dispensed in public health outpatient pharmacies, noted that “aspirin… leads all other drugs in volume of output” (p. 933). Yet historians have reported that at that time, “no one since… Heinrich Dreser [who died 1924] had actually bothered to investigate its mechanism” (Jeffreys, 2005, p. 220), and that at a celebration in the late 1950s of aspirin’s major US manufacturer’s production of its 100-millionth pound of aspirin, the industry’s keynote speaker noted that the “means by which aspirin succeeds in moderating pain” (p. 219) was still an open question. Yet the discovery by Vane (1971) of physiological mediating pathways was worthwhile: Over time, Vane’s discovery led to additional benefits, such as increased understanding of several basic physiological processes, and aspirin’s use in additional practical applications, such as age-tailored regimens to protect against cardiovascular disease (Collier, 2024; Jeffreys, 2005; US Preventive Services Task Force, 2022).
The benefits of mindfulness programs are not quite so dramatic and clearcut as the benefits of aspirin, however. Nor do their most noteworthy benefits generalize across groups so readily, with so little adaptation. Therefore, ongoing empirical and theoretical research on mindfulness and meditation impact processes is clearly needed to understand sociocultural and individual patterns of benefit and safety, and to guide optimal mindfulness adaptations and analogues. The next subsection argues that an optimal intervention may often be an analogue that maximally resonates with a population’s inherited worldview.
Practical Action Amidst Theoretical Heterogeneity
Absent unexpectedly dramatic theoretical progress, efforts to carry out the four tasks listed above—whether for clinical applications or for public health—will likely need to proceed on an evolving, iterative, and partially ad hoc basis, drawing upon theories deemed most compelling and relevant to the population to be served. Theorizations drawn from a community’s own worldview may often be deemed compelling by that population, and should thus be given a “seat at the table” (Minkler, 2010, S81; see also Albert et al., 2023).
Developing the needed common understandings among community and professional partners might to some degree be viewed as a participatory research process (Cargo & Mercer, 2008; Levac et al., 2019). In such circumstances, public health partnerships may draw upon emerging tools for identifying and developing common ground. For example, recent public health initiatives have successfully used a method called by the possibly off-putting name of fuzzy cognitive mapping (FCM), “a practical tool in participatory research [whose] main use is clarifying causal understandings from several knowledge sources” (Sarmiento et al., 2024b, p. 1). As “a graphic technique to describe causal understanding” (Sarmiento et al., 2024a, p. 1), FCM “provides a shared substrate or language for sharing views of causality [making] it easier for different interest groups to agree what to do next” (Sarmiento et al., 2024b, p. 1). FCMs have been used, for example, to integrate conventional and aboriginal perspectives on diabetes and its management (Giles et al., 2007). The method first emerged in the 1970s and 1980s in political science and computer science, and since that time has been used in fields that range from social science to biomedicine to artificial intelligence (Axelrod, 1976; Kosko, 1986).
Expanded-Hub Adaptation
What may be some of the major issues to bear in mind when building theoretical consensus for needed action? Palitsky et al. (2025) have made an important suggestion relevant to progressing effectively with impact theory heterogeneity. They use the phrase “hub-and-spoke” to refer to the widely prescribed sequence of processes that is based on (i) identifying an intervention’s ostensible “core components,” followed by (ii) “identifying the needs for adaptation, and then modifying the intervention in such a way that its core components are preserved while addressing the adaptation needs.” Palitsky et al. (2025) were concerned, however, that such widely prescribed hub-and-spoke adaptation processes “are most suitable for interventions whose core components are well understood and empirically verified,” which is not the case with mindfulness-based programs (MBPs). Instead, they suggest that “mindfulness needs a bigger hub, one that encompasses elements that primarily exist at the ‘spokes’… a conceptual expansion of the ‘core’ of mindfulness to include elements and changes that are successfully introduced in the process of cultural adaptation.” Examples of such elements could include interventions such as Centering Prayer among Christians (Knabb, 2012), as well as adaptations they mentioned from China and Australia. They arguably might also include various analogues mentioned in the target article.
The expanded-hub approach advocated by Palitsky et al. (2025) has much to be said for it, and is perhaps not as novel as it may seem. As noted in a recent history of meditation research (Oman, 2021), new scientific research fields commonly employ simplified procedures and conceptions because they initially need such simplification to make their empirical task tractable. From that perspective, “several dominant trends in meditation research appear to have provided gifts of temporary simplification that the field has needed” (p. 46), such as the comparative neglect by Transcendental Meditation of ancillary practices (e.g., “informal practices” and “mindfulness qualities” as incorporated in MBSR). But then, “after a period of simplification, researchers have re-engaged with the temporarily marginalized facets of meditation, and re-aligned their models with the breadth of the phenomenon under study” (p. 46).
Committing to the expanded-hub approach by Palitsky et al. (2025) could go a long way toward re-aligning the mindfulness field with its roots in the rich multicultural field of meditation and contemplative practice application and scholarship. And a strength of their proposal is its emphasis upon continuity: The current “hub” of MBSR and other so-called MBPs is not abandoned, but is rather positioned within a larger corpus—a larger hub—of programs and interventions that possess what Peterson and Seligman (2004, p. 35) called a mutual “coherent resemblance.”
But what exactly should be the limits of such an expanded hub? Perhaps there lies the rub. Palitsky et al. (2025) recommended a “conceptual expansion of the ‘core’ of mindfulness to include elements and changes that are successfully introduced in the process of cultural adaptation” and adoption of “common adaptation principles.” But without further specification, there would seem to be scope for considerable disagreement over what counts as “successful,” perhaps risking a variant of “concept creep” (Harper et al., 2023; Haslam et al., 2020).
Rosch (2013), however, has articulated a simple hub-expanding suggestion that would enlarge the pool of interventions recognized as relevant: “bringing the research on mindfulness back to the context of contemplative practices as a whole might help serve as a corrective to some of the blind spots in the study of mindfulness” (pp. 244–245). Such a shift—if seriously integrated into the mindfulness field—could go a long way toward resolving the mindfulness field’s lag in cultural inclusiveness that impedes its integration into public health. Considering questions about mindfulness from such an enlarged perspective would also stimulate the mindfulness field with a fresh infusion of concepts and empirical findings relevant to causal mediation and intervention research (e.g., Farias et al., 2021; Goleman, 1988; Oman, 2010; Shapiro & Walsh, 1984).
Moreover, contemplative practice seems well-accepted and uncontroversial as a technical name for the type of intervention to be encompassed by such an expanded hub. Besides Rosch’s use quoted above, the phrase “contemplative practice” has been widely used elsewhere (Crosswell et al., 2024; Farb et al., 2015; Plante, 2010). In this issue, for example, it has been used in the commentary by Knabb and Vazquez (2025) to refer to the Christian meditation intervention they have studied, and in the title of the commentary by Galante and Van Dam (2025), who also approved of “including mindfulness within the contemplative studies field.”
To return to the topic of “mechanisms,” improved approaches to understanding MBP causal effect mediators—in the language of Galante and Van Dam (2025), better approaches to “retroactively build an academic theoretical and empirical framework around” MBPs—could potentially arise from repositioning the mindfulness field solidly within the broader study of contemplative practices. Like MBSR, many other systems of contemplative practice involve a foundational sitting meditation or “formal” practice, plus additional or “ancillary” practices (Oman, 2021; Plante, 2010). Like MBSR, most or all other systems include some form of emic or “face theory” that explains how the various practices work together to “retrain attention”—the “single invariant ingredient in the recipe… of every meditation system,” in the apt phrasing of Goleman (1988, pp. 107, 169). And, like MBSR’s face theory, other systems’ face theories typically also include some account of how ancillary practices operate as part of what Goleman calls “the same basic formula” underlying all meditative systems, “the diffusion of the effects of meditation into the meditator’s waking, dreaming, and sleep states” (p. 112). I submit that much insight about causal processes might emerge from studying all these interventions in comparative perspective.
How might such causal mediation be conceptualized and studied in a comparative context? The rudiments of such an approach have been sketched by Rosch (2015), who as Sedlmeier (2025) noted, has clearly articulated how MBSR can be regarded as a “complex intervention” (Hawe, 2015; Petticrew, 2011). Rosch (2007) characterized MBPs as employing “mindfulness… as an umbrella justification (‘empirical’) for the inclusion of other aspects of wisdom that may be beyond our present cultural assumptions” (p. 262), and then went on to offer a “template of the factors at work” in MBSR, suggesting that “there are alternative ways that each of the factors can be instantiated… even religions could use the factors by substituting methods for achieving them based on their own beliefs” (Rosch, 2015, p. 279).
A similar “template” approach—essentially a list—can be used, I suggest, to study many individual contemplative practice systems (e.g., see Oman et al., 2008; Shapiro et al., 2008). And over time, such template approaches could be adjusted to generate comparative insight on common as well as unique elements in practice systems and their face theories, as well as insights about how effects from these complex interventions are causally mediated. Much MBP research has been quantitative, but template-informed qualitative or ethnographic analyses of interventions might yield much insight. How, for example, do intervention instructors and recipients narrate the uses and mutual synergies of various intervention practices (e.g., Oman et al., 2008; Rosch, 2015)? How do they narrate the benefits of committing to routine formal practice?
Additional Suggestions for Exploration
At the current juncture of heterogeneously theorized mindfulness mediation research, I have three additional suggestions for specific elements and theories that appear to merit consideration. Each is compatible with an expanded hub, or repositioning of the mindfulness field within contemplative practice, as suggested above.
First, to address another “blind spot” in mindfulness research, the field should devote more attention to theorizing and exploring how mindfulness and other meditative interventions relate to habit formation—and in particular, to building novel salutary health behavior routines. Regarding health behaviors other than meditation itself, evidence supports the helpfulness of MBPs for dissolving maladaptive health behaviors such as substance misuse (Li et al., 2017). However, there is surprisingly little systematic evidence that MBPs can support establishing novel proactive salutary behavioral routines, such as physical exercise routines (Creswell et al., 2019; for physical activity, Schneider et al., 2019 reported four null, two favorable, and one unfavorable randomized comparisons between mindfulness meditation and controls). Perhaps the only well-documented support given by MBPs to positive health routine formation is support for formal meditation itself: MBP intervention recipients are reasonably but not outstandingly adherent to home practice recommendations (e.g., practicing 64% of the assigned time, versus 70% average adherence overall for behavioral change interventions, DiMatteo, 2004; Parsons et al., 2017). Such support is very important, as establishing regular formal meditative practice is widely understood as a key mediator of meditative intervention benefits, and encouraging regular home practice is thus drawing appropriately intensified scholarly attention (e.g., Miles et al., 2023; Sharma et al., 2021).
But what accounts for the weak evidence that MBPs can foster non-meditative salutary habit formation? A question of interest is whether such positive habit formation deficiencies apply only to MBPs, or more broadly to diverse sitting contemplative practice systems. A basis exists for hypothesizing an MBP-specific limitation: Substantial discourse and reflection on positive habit formation is clearly present in many if not most religious traditions (e.g., Pawl, 2023; note also reference to “language of formation” in commentary by Sandage & Stein, 2025), but is noticeably absent from secularized mindfulness literature—for example, books by Kabat-Zinn (1990, 1994) use the word “habit” with an almost exclusively negative valence, as if habits were never healthy, and always disempowering. And whereas PsycInfo searches for “habit formation” retrieve more than 1000 records overall, they only retrieve three publications from a journal or book with “mindfulness” in its title, with searches for “healthy habit,” “wholesome habit,” or “good habit” anywhere in mindfulness-titled journals or books retrieving only a single record (Miles et al., 2023). Perhaps MBPs can be valuable aids, not yet empirically documented, to positive health behavior formation—but at present there is scant or negligible evidence, and we clearly need better understanding of the relation between various meditative practices and positive habit formation.
Importantly, although silence about positive valences of “habit” might have served useful purposes—perhaps setting a tone for the operation of MBP face theory and pedagogy—such silence seems of dubious adaptiveness for theory-building about mediators. Nor is such silence, or such a “blind spot,” required by contemplative traditions broadly, by Indic traditions, or even by Buddhism, which Sedlmeier (2025) suggested as one “natural starting point for a theory of mindfulness practices.” For example, de Silva (1979, p. 78) reported that “persistence and habit” is a principle meaning of the Buddhist concept sankhāra, which might be translated as “conative disposition,” and that such conative dispositions “may be divided into wholesome and unwholesome” (p. 78). Similarly, the Yoga Sūtras of Patañjali refer to beneficial wisdom-born saṃskāras, sometimes translated as “mental impressions,” that classical commentators describe as beneficial, noting that “wisdom, or discrimination… produces its saṃskāras just as all activities [of the mind] are bound to do” (Bryant, 2009, p. 162; Whicher, 2005).
Could such Indic concepts inform scientific attempts to theorize how meditative interventions—both MBPs and those built on other discourses—do or do not support establishing positive health behaviors? Or support cultivating compassion or other “mindfulness qualities”? Seemingly unexplored, for example, are how such Indic conative constructs might inform or be integrated with the influential and conatively relevant “cognitive-affective mediating units” theorized by Mischel and Shoda (1995, p. 246), or other more recent node-based theories of personally persistent conative dispositions and qualities (e.g., Fleeson & Jayawickreme, 2015; Warren et al., 2023; Wright et al., 2021). Perhaps such theories could also shed light on the question posed by Sandage and Stein (2025) about whether mindfulness itself—perhaps initially understood through a traditional Buddhist conceptualization—can be understood as a virtue, or whether it must be understood simply as a “tool.”
My second suggestion is that if there is any single new “element”—Palitsky et al.’s word—that especially merits consideration for integration into an expanded hub of MBPs, it is portable spiritual mantram repetition, mentioned in the target article as the core of a mindfulness analogue program, the Mantram Repetition Program (see also Appendix). Portable mantram repetition is very simple, widely cross-culturally prevalent, possesses a solid and increasingly transdiagnostic evidence base for benefit, fosters documented increases in (widely used albeit debatably valid) mindfulness measures, and has generated validated train-the-trainer approaches (Bormann et al., 2014; Buttner et al., 2016; Oman et al., 2022; Oman, 2024b). Even for MBP variants that retain “mindfulness… as an umbrella justification” (Rosch, 2007, p. 262), it would seem quite feasible to include mantram repetition as an aid to mindfulness under the umbrella of the MBP’s mindfulness-centered face theory (Oman et al., 2022; see also Waelde, 2022). Moreover, Gethin (2011, p. 270) reported that “ancient Buddhist texts understand the presence of mindfulness as in effect reminding us of who we are and what our values are,” and for many people, one may suspect that such a traditional value remembrance function of mindfulness would be better served by portably attending to repeating a mantram or holy name, than by attending to the breath.
The final suggestion is that the role of the mindfulness or meditation program instructor’s own practice may merit more theoretical elaboration and likely affirmation as a key causal factor. Kabat-Zinn (2003, p. 149) has insisted that some necessary skills for program instructors “can come about only through exposure and personal engagement in practice” (p. 149), going so far as to state that he personally considers “sitting long [dharma] teacher-led retreats periodically to be an absolute necessity in the developing of one’s own meditation practice, understanding, and effectiveness as a [mindfulness] teacher” (Kabat-Zinn, 2010, p. xii). Kabat-Zinn (2003) also wrote that in developing MBSR, “One major principle that we committed to was, and still is, never asking more of our patients in terms of daily practice than we as instructors were prepared to commit to in our own lives on a daily basis” (Kabat-Zinn, 2011, p. 290). Such insistence on the influential role of an instructor’s own personal (and home) practice diverges from the compartmentalization of work and personal life that is normative in most secular spheres of modern Western life, especially spheres that have become dominated by what sociologist Max Weber called formal rationality (Kalberg, 1980). (It also seems irreconcilable with proposals to replace human instructors with artificial intelligence, as per Tan, 2025.) But such affirmation is consistent with millennia of traditional educational understanding (del Castillo & Sarmiento, 2022; Oman, 2013a; Raina, 2002; Warnick, 2008). The mindfulness movement’s wide dissemination of this significant norm across many sectors of society is exceptional, perhaps unparalleled in recent years, and may plausibly have provided much collective benefit. Has today’s mindfulness movement begun building an important institutional middle ground between the dominant and compartmentalized secular forms of education, and the insights of holistic traditional education? Regardless of how one may answer such deeper questions, theorization of causal effects from MBPs would seem incomplete without fuller attention to causative influences from the instructor’s personal practice.
Collective-Level Mediating Processes
Importantly, interventions may affect population health not only by directly acting on individuals, but also by acting through the sociocultural, attentional, and even physical environments in which individuals live their lives. For example, ensuring abundant sidewalks can directly encourage individuals to exercise by making such exercise physically safer and easier. Each individual’s improvements may subsequently encourage that individual’s family, friends, or associates to exercise, and their increased engagement in exercise may in turn “contagiously” spread still more broadly, as well as reinforce the original individual’s engagement in exercise. In parallel fashion, interventions that enable individuals to give up health behaviors such as smoking can benefit both the focal individual and the larger community (Zollinger et al., 2004). And the dynamics of herd immunity—or its waning—illustrate how dramatic population health changes, favorable or unfavorable, may result from crossing a population proportion tipping point (Fine, 1993; Kidd et al., 2003; May & Silverman, 2003).
Similar dynamics can also apply to mindfulness and meditation interventions. Just as vaccinating enough individuals can produce herd immunity or other protection, “spillover” effects may potentially arise from individual-level interventions, such as meditation programs (Chaney et al., 2016; Francetic et al., 2022; VanderWeele & Christakis, 2019). In theory, such spillover may be very positive, as implicit in aspirations for a mindfulness-derived “global renaissance” (Kabat-Zinn, 2019, p. xiii), or to reduce crime rates through sufficient population uptake of meditation (Hagelin et al., 1999; see Farias & Wikholm, 2015, for critique). On the other hand, such spillover may potentially be negative, as expressed in the warning by Walsh and Shapiro (2006, p. 228) against decontextualized Westernized meditation as “colonization of the mind” that undermines indigenous psychologies. Negative spillover concerns also permeate the parallel, noted in the target article, between the resistance to spreading modernized mindfulness programs, and worldwide efforts to protect local breastfeeding cultures from aggressive direct-to-consumer marketing of infant formula (Sethi, 1994).
Such spillover effects—both favorable and unfavorable—may sometimes operate interpersonally (e.g., Montes-Maroto et al., 2018), but over time may also operate by shaping norms and cultural understandings embedded in collective sociocultural and attentional environments (see target article’s Axes A7 and A8), including influences embedded in physical environments (Altay & Porter, 2025). To date, with the partial exception of investigations into so-called collective mindfulness (Sutcliffe et al., 2016), there have been few if any attempts by mindfulness scholars to review theories and evidence for effects from MBPs on collective environments. Such reviews could be very helpful for progress in conceptualizing, measuring, and understanding collective-level spillover dynamics, and any further effects—any further “ripples”—that they may cause.
Preventing Cultural Imperialism
Whereas Kabat-Zinn (2019) and others have emphasized the possibility of positive collective effects, the target article as well as several commentators have cautioned about risks of adverse collective effects. Among commentators, Farias (2025) characterized “the mindfulness model we are using [as having] agglutinated key ideas of Western modernity, such as a heightened individualism, ideals of self-expression, and a hyper-focus on experience of the present.” He has evident concern that allowing such cultural reconditioning to be embedded into an intervention may be inappropriate and foster various adverse outcomes. Several other commentators expressed similar concerns relating to cultural colonization (e.g., Galante & Van Dam, 2025; Palitsky et al., 2025; Wang, 2025).
For many reasons, I very much share such concerns. In spite of its triumphs, Western modernity is encumbered by many adverse tendencies that it has yet to consistently shed, including not merely the propagation of adverse health practices, but also deep entanglement with catastrophic environmental unsustainability (e.g., Gilmore et al., 2023). From the standpoints of ethics, health, sustainability, and cultural inclusiveness, there are numerous reasons to support cultures worldwide in finding their own pathways to their own forms of sustainable “modernity”—that is, pathways to their own forms of sociocultural organization that integrate the use of sustainable technologies with cultural supports for discerningly managing perennial existential challenges (Eisenstadt, 2000; Pargament, 1997; Smith & Vaidyanathan, 2011). These perennial existential challenges include the impermanence of people’s physical bodies and the impermanence of the temporal order, and all major religious traditions provide support for addressing them (Okon, 2005; Van Uden & Zondag, 2016). On this core modern task of technical and existential reconciliation, we may hope that not only nations, but also to some degree civilizations, may learn from each other and emerge as a functioning “community of practice” (Adler, 2010; Wenger, 2000).
Much of the needed technical/existential reconciliation can only come through cultural change, but such cultural change will surely be reflected, and may at times be enabled, by policies that support mindful and contemplative practices and orientations across societal sectors. Such policies will inevitably vary in form and function between nations possessing diverse administrative structures and cultures (target article, Axis A11). Most fundamentally, such policies may aim to protect the health and safety of the public through the public health assurance function—for example by mandating proper safety procedures for meditative interventions, as discussed earlier. Policies could—and arguably should—also be crafted to prevent cultural colonization and support the development of indigenously derived contemplative practice interventions—consistent with concerns expressed by several commentators (Farias, 2025; Galante & Van Dam, 2025; Palitsky et al., 2025; Wang, 2025). Beyond assurance, policies could also potentially emphasize cross-sectoral promotional integration of mindful or contemplative approaches into diverse societal sectors ranging from workplaces to education, thereby helping to rebalance and reweave the types of rationality that are used in different sectors (Kalberg, 1980).
How might beneficial protective and promotional policies be developed and implemented? To aid in needed policy formation, public health has devoted increasing attention to a set of policy-relevant constructs, one of which is the notion of epistemic community (Greer et al., 2018; Mamudu et al., 2011). An epistemic community is definable as “a network of professionals with recognized expertise and competence in a particular domain and an authoritative claim to policy-relevant knowledge within that domain or issue-area” (Haas, 1992, p. 3). Much mindfulness work in recent decades has attempted—arguably with only partial success (e.g., Bristow, 2019)—to endow the field with the features of a policy-impactful epistemic community, such as a claim to authoritative knowledge. But the authority of such claims has been limited by numerous factors noted in this special issue, including lack of intercultural and interfaith generalizability, and other weaknesses in the research base. Must these weaknesses enduringly circumscribe the ability of the mindfulness movement, broadly understood, to beneficially affect policy?
Importantly, recent mindfulness research has predominantly pursued only a single (implicit) model for how to impact policy: Scientifically asserting the importance of an ostensibly culturally neutral and universal psychological factor. But while many epistemic communities are comprised of scientists, other groups asserted by scholars as epistemic communities include religious leaders, judges, diplomats, bankers, international lawyers, defence experts, and tobacco control professionals (Cross, 2012; Mamudu et al., 2011; Sandal, 2011). More firmly situating mindfulness within the broader study of contemplative practices, as suggested by Rosch (2013) and other commentators, could arguably open multiple additional avenues for policy influence. Perhaps most immediately, such repositioning might permit stronger alliances with religious leaders. Moreover, Sandal (2022, p. 198) has noted that for some policy-relevant issues, differences between views of diverse religions “might be smaller than the difference between religious and secular approaches… which paves the way for interfaith dialogue.” In addition, while much progress in intercontemplative skill-building is undeniably needed, an expanded-hub conception of the mindfulness field, encompassing experts in diverse types of traditionally derived contemplative practices, could build upon emerging understandings of deep similarities between traditional contemplative paths (e.g., Rose, 2016; Sparby, 2019), and could arguably evolve into a considerably more robust and policy-impactful epistemic community over the long run. If soundly built, such an expanded field should be well-positioned to prevent or oppose any lingering contemplative cultural imperialism.
But at present, modernized mindfulness programs do appear at risk of generating collectively mediated adverse effects to the extent that they propagate adverse “agglutinated” ideas mentioned by Farias (2025)—or propagate a culturally disempowering “colonization of the mind,” driving a wedge between other civilizations and their abilities to draw upon their own indigenous contemplative heritages. Such disempowerment, when induced by ostensibly healing modalities and professionals, has also been called cultural iatrogenesis (Illich, 1975; Oman & Thoresen, 2003). How great is the risk of such cultural disempowerment and iatrogenesis from mindfulness? I think that the risks could be minimized if the mindfulness movement commits itself to using an expanded and culturally inclusive hub as suggested by Palitsky et al. (2025), with proactive equal inclusion of supportable indigenously derived contemplative practices. Thus, my answer to Farias’ (2025) question of “why not develop the research literature on contemplative practices to include the systematic study of other meditation varieties?” is as follows: I very much agree that this is highly desirable—indeed, imperative.
I do suspect, however, that there will also be a continued role in many civilizational regions for meditative programs that, like contemporary MBPs, are secularized. Stably integrating the best of new technologies and the best existential supports from traditional wisdom has been a protracted process in every civilizational region. Nor does the task anywhere seem complete. In such conditions, it is hard to forecast what will be popular—and Burke (2012) found that preferences for specific methods of meditation sometimes varied by age, suggesting that at least in the US context, “meditations have their moment of cultural relevance and are then eclipsed by newer methods” (p. 241). Will MBPs retain or gain popularity in sociocultural groups similar to the middle-class professionals with whom they have been especially popular in the West? Globally, the proportion of people self-identifying as religious is projected to increase by 2050, and the unaffiliated portion to decrease (Pew Research Center, 2015). Still, despite claims that society is now “post-secular”—that is, now characterized by the persistence and resurgence of religion—it would seem prudent to remain detached and open-minded about the types of meditation that will become popular in the future (Moberg et al., 2017).
Ethical Impacts of Mindfulness Interventions
Berryman (2025) has expressed concerns about two types of collective-level effects: effects related to inappropriate generalization, and effects related to ethics. First, Berryman (2025) noted a variety of groups that have been understudied in research on MBPs and other mindfulness-based interventions (MBIs). These groups include neuro-atypical individuals, and those with isolationist tendencies. Berryman (2025) judiciously reminded us that findings from typical populations may not generalize to these groups. These are relevant facets of the mindfulness field’s overall responsibility to prevent adverse effects from interventions—either in groups or in individuals.
Berryman’s commentary’s main focus, however, was the potential for adverse effects of MBIs on moral functioning—a term that he did not define, but implicitly concretized with reference to a multidimensional framework that he has developed (Berryman et al., 2023). This framework offers guidance on empirically studying an intervention’s “impact” on multiple specific facets of moral functioning, such as “moral judgment,” “moral emotions,” and “moral behaviors.” (pp. 916, 919). Importantly, ideas about moral impacts have been of interest to human groups throughout history, and have informed public debate about issues such as the prohibition or regulation of alcohol, for which “comparisons across countries reveal the central role played by cultural factors” in how alcohol is regulated and understood (Walsh et al., 1989, p. 49). Similarly, even within societies, views may differ, in a manner not readily adjudicated by empirical research, on the short- and long-term implications of controversial recent public health programs such as providing human papillomavirus (HPV) vaccines to teens, or needle exchange programs for drug addicts (Bowen, 2012; White, 2014).
Thus, even as further research may identify theoretically interpretable moral impact processes from MBPs that are a mix of salutary and detrimental (e.g., Brendel & Hankerson, 2022; Li et al., 2025), key practical questions will include how these competing impacts are evaluated and weighted by individuals and communities, as well as how to enhance the good and mitigate or eliminate the bad. Proactive mitigation measures may be particularly desirable when influences from an MBP are received synchronously by an entire group or organizational workforce, either through an MBP-inspired change in leadership style (e.g., Li et al., 2025), or through synchronous MBP training of individual workers. Such cases raise the possibility of adverse collective-level dynamics, such as harmful synergies between individual MBP-induced moral decrements.
Seemingly largely absent to date, however, are clearly documented cases of adverse moral synergies that are compellingly or even plausibly attributable to MBPs or other meditative interventions. A hypothetical example might be an ethical lapse by an organization that is plausibly attributable to a workforce MBP training (Chapman et al., 2023). Without such documentation, I am inclined to think that many communities and public health officials will view the risks of moral decrements from MBPs as small, and perhaps best managed as part of individuals’ informed consent choices to receive mindfulness or meditative training.
A few important examples arguably do exist, however, of adverse individual moral impacts—but are typically controversial. One example is the perception of negative moral effects by some religious communities who have regarded MBPs as an adverse form of “stealth” proselytizing (Brown, 2019). Here, one perceived risk is depriving individuals of the moral treasures of their own religious traditions, a form of moral harm. Yet such interpretations remain controversial, as not all observers agree that MBPs in fact represent stealth proselytizing. However one may conceptualize the nature of the harm, such concerns might often be practically addressed by offering religious adaptations as alternatives. This is closely related to the issue noted earlier of preventing colonization, perhaps also best addressed through expanding the mindfulness “hub” to include appropriate religious analogues and adaptations. (As noted in the target article, “local resistance to mindfulness programs on religious grounds might be viewed … from a global perspective as part of widespread efforts to enlist policy in defense of facets of local culture deemed salutary,” Oman, 2025, Axis A11.)
Another concern is that MBPs have been misleadingly used to displace attribution for workplace stress from working conditions onto individual workers (Purser, 2019, and target article, Axis A7), partly by disengaging individual workers from their moral responsibility to address adverse workplace conditions (Li et al., 2025). This process has been called moral disengagement (Bandura et al., 1996). But to what extent does such displacement arise from the organization’s framing of the MBP, rather than the MBP’s direct effects on individuals? Whether or not MBPs are more vulnerable to abusive framing than other stress management programs, it would seem possible, as Berryman (2025) suggested, to integrate ethical components into MBPs in such settings—perhaps in this case specifically designed to prevent adverse moral outcomes, such as workplace moral disengagement.
Berryman (2025) has made a case that “ethical motivations” could be viewed as another potential axis beyond the 14 axes mentioned in the target article. The present author is inclined to agree that commitment to ethics is a valid and instructive axis of comparison between the fields of public health and mindfulness, if it can be borne in mind that what counts as an ethically acceptable balance may depend in part on community values and other contextual factors. Moreover, clinically rooted mindfulness scholars and practitioners should be aware of “the now familiar dilemma that traditional theories of clinical… bioethics are not transferrable directly to public health ethics,” especially because whereas clinical medicine focuses on the patient-provider relationship, the core of public health is its responsibility for the health of the community (Lee, 2012, p. 85). Therefore, across many public health ethical frameworks—of which none is predominant—a commonality is “the need to balance respect for individual autonomy with the field’s obligation to prevent harm and protect health,” which Lee (2012) sees as “a clear move from the values of liberalism in bioethics toward the collective of community in public health ethics” (p. 95). Bearing in mind these varying yet arguably complementary ethical perspectives will help ensure more successful integration of mindfulness and other meditative practice systems into public health theory and practice.
Collectively Mediated Benefits of an Expanded Hub
Although collective-level spillover from indiscriminately implemented MBPs and MBIs can risk cultural colonization and perhaps moral decrements, no discussion of collective-level mediation would be complete without mentioning the potential for salutary spillover effects. The potential for mediation of benefits through collective environments has remained largely theoretical rather than empirically tested, as noted in in the target article (Oman, 2025, Axis A7). Theorized processes through which individual mindfulness spills over to affect other individuals have included conversations and other interpersonal processes, as well as “norms or systems of interaction” and other enduring social environmental features that are “reciprocally and tightly linked” to conversations (Sutcliffe et al., 2016, p. 71). Open questions include whether “factors such as group norms or leader behaviors [are] necessary for translating individual mindfulness” into organizational-level qualities such as “sensitivity to operations” (qualities that Sutcliffe et al., 2016 and others have called “collective mindfulness,” p. 59).
For conceptualizing such spillover and collective-environment mediation processes, a useful point of departure could be the “template” framework that Rosch (2015) provided for understanding causal effects from MBPs. Her template is unencumbered by the empirically poorly supported presupposition that mindfulness itself is the primary driving mediator of all effects from MBPs—which is not to question that assumption’s historical efficacy as a support for face theory and branding. And as noted earlier, template approaches such as suggested by Rosch fit well with repositioning the mindfulness field within the expanded hub of contemplative practices within diverse religious contemplative traditions (Palitsky et al., 2025).
In such an expanded-hub template approach, for conceptualizing interpersonal spillover mediation processes, one could recognize as potential spillover mediators not only the “loving kindness and compassion” that Rosch (2015, p. 283) identified as part of the MBSR template, but also additional attitudinal or dispositional factors recognized as supportive in other contemplative traditions, such as truthfulness, focus, justice, and perhaps moral elevation (Oman, 2010; Yaden et al., 2017; more broadly, consider also Peterson & Seligman, 2004; Wright et al., 2021). And we can conceptualize such factors or their supports as potentially integrable into social environments not only through “norms or systems of interaction” (Sutcliffe et al., 2016, p. 71), but also through other features of collective attentional environments, ranging from physical features, to official communications, to the design of software (see target article, Axis A8; see also Oman, 2013b, section on “Multiple Levels for Intervention,” p. 198).
Collective Mediators in Multi-Level Interventions
Finally, as noted in the target article (Axis A7), multi-level interventions are recognized as the state of the art in public health. Commentators have offered several stimulating suggestions regarding multi-level interventions. Galante and Van Dam (2025) have suggested offering organizational interventions with program variants embodying “different actions and different aims to be implemented at each level” of organizational hierarchies (i.e., leaders, managers, rank, and file). Such an intervention, if designed in light of organizational dynamics and thoughtfully tailored to each level (perhaps even with level-specific ethical components), would indeed be an important step towards multi-level intervention.
Palitsky et al. (2025) also suggested that “MBIs should be implemented in a way that directly supports the provision of… critical resources” such as “basic safety, sanitation, food, housing, money, and primary healthcare” and other social determinants of health. The present author agrees that mindfulness and meditative implementation should support addressing social determinants of health. But he is not sure what they mean by “directly” supporting provision of critical resources, since budgets are finite, and mindfulness intervention staff could hardly be expected to have expertise in providing sanitation, medical care, or basic safety. He can therefore more unhesitatingly agree with the formulation by Galante and Van Dam (2025) that we should consider “how mindfulness, as one of many interventions, could contribute to public health,” even as we should be careful to avoid “helping perverse systems create more harm by masking the effects of poor social and structural conditions on health while making people more accepting of these conditions.”
Last but not least, multi-level interventions typically aim to modify collective environments directly, rather than through processes of spillover from individual interventions. Galante and Van Dam (2025) agreed with the target article’s suggestion that, in their words, “some of these [dispositional mindfulness] measures might be beneficially reframed as assessing facets of attentional health.” More broadly, if MBPs or other meditative programs are understood as contributing to attentional health, collective-level intervention components, such as the “right to disconnect” laws mentioned in the target article, can also be understood as aiming to support that same need: Attentional health. Such collective-level intervention components may directly affect one facet of an attentional environment, but operate through distinctive collective-level change processes and pathways to beneficially affect other facets of attentional environments (Axis A8), such as social norms or physical environments—and thereby, through all of these facets of the environment, beneficially affect individuals.
Altay and Porter (2025) have helpfully pointed out that attentional health can be facilitated by certain types of physical environments, such those that demand effortless attention, foster a sense of coherence, or remove a person from spaces of habitual effortful activity. Creating such physical environmental features is a potentially worthwhile component of a multi-level attentional health intervention.
Physical, social, and attentional environments across many sectors may involve not only design, but also signage and decoration, which can also influence well-being. For example, school campuses and corporate or nonprofit workplaces may convey organizational messages that either support or undermine individual and collective attentional health (including mindfulness qualities such as listed in Table 2 in Oman, 2025). Representations of meditative or mindful spiritual perspectives may potentially be integrated into such social environments not only as interventions on offer (Aldbyani, 2025; Buttner et al., 2016; Knabb & Vazquez, 2025; Wang, 2025), but also as architectural spaces, messages, images, or even assigned human beings, such as chaplains (Gilliat-Ray, 2005; Oman, 2024a). For decades, for example, the United Auto Workers has trained hundreds of chaplains, implementing programs in numerous factories across the USA (Plummer, 1996; Waller, 2012). One core function of chaplains is to provide “presence,” a quality that overlaps with mindfulness (Adams, 2019). Furthermore, in many countries, chaplains have sometimes played “a critical role in highlighting injustices” in the workplace, aiming for their redress (Wolf & Feldbauer-Durstmüller, 2023, p. 1151). Shifts in attentional environments induced by such potential multi-level intervention components represent candidate collective-level mediators of attentional health (including mindfulness) and its physical and mental health sequelae.
Of course, the legal, cultural, and even ethical affordances for formally integrating diverse spiritually or religiously derived mindfulness supports into social environments vary considerably between countries and cultures. Yet despite great diversity in national law codifications, the post-WWII era has seen the emergence of a considerable and widely accepted body of internal law—a set of “international norms”—on freedom of religion (Witte, 2010, p. 406; see also Tushnet, 1999). And for many decades, there has been ongoing discussion at the World Health Organization of how spirituality is relevant to health, and what should be done about it (Peng-Keller et al., 2022). Globally minded mindfulness scholars socialized into US understandings of secularism, however, may benefit from knowing that “conspicuously absent from international human rights instruments … are the more radical demands for separationism, rooted in the popular American metaphor of a ‘wall of separation between church and state’” (Witte, 2010, p. 412), and that the “purging” of some tax-supported institutions, such as public schools “of virtually all religious symbols, texts, and traditions, in favor of purportedly neutral and secular tropes, stands in considerable tension with international principles of religious equality” (p. 416). For comparison, about two-thirds of countries—not including the USA—make a provision for health or healthcare in their national constitution (Kinney & Clark, 2004). Such legal context may be relevant to understanding affordances for the future global adoption of mindfulness and contemplative practice interventions, and how they might be included in multi-level interventions in a manner that is legal, culturally sensitive, and ethical.
Religious and Cultural Adaptations and Analogues
A recurring theme among commentators has been the prevalence across religious traditions of analogues to mindfulness, and their relevance to the cross-cultural use of contemplative practice interventions. Above, the present author agreed with the concern, expressed by several commentators, to prevent cultural colonization (Farias, 2025; Henning et al., 2025; Palitsky et al., 2025; Wang, 2025; see also similar concerns expressed by Sandage & Stein, 2025). This section responds to additional commentator themes, including the usefulness of an interreligious developmental perspective (Sandage & Stein, 2025), needs of religious minorities (Sandage & Stein, 2025), bridging concepts, and the importance of avoiding inappropriate assertions of equivalence by respecting differences between traditions.
One of the more novel and dynamic contributions on religious adaptations was provided by Sandage and Stein (2025). They illustratively applied a developmental model of interreligious competence (DMIC, Morgan & Sandage, 2016) to various issues that may arise when integrating mindfulness into public health. To illustrate how DMIC categories such as “denial,” “minimization,” “acceptance,” or “adaptation” may arise in the context of mindfulness and meditation interventions, Sandage and Stein (2025) provided “examples of stances by helping professionals… constructed [as] composites based indirectly on professional and training situations we have observed.” Such concepts and illustrative examples represent valuable or perhaps foundational resources for developing needed trainings for mindfulness and meditation instructors in interreligious and intercontemplative competence. Such trainings should arguably become standard for instructors implementing either stand-alone or ensembles of multiple alternative contemplative practice interventions in religiously diverse settings, consistent with the admonition by Roberts and Crane (2021, p. 196) that it is “imperative that we all participate in training on, and proactively raise our awareness of, equality, diversity, inclusion, and conscious and unconscious bias.”
Also relevant to such trainings, and arguably also to issues of intervention branding (Axis A14), is another illustrative application of the DMIC by Sandage and Stein (2025). They applied the DMIC to a tradition, in this case Judaism, that experiences the “task of the religious minority,” including a comparatively greater need for attention to collective self-preservation. Sandage and Stein (2025) speculated that adopting elements of mindfulness into practice by some Jewish communities may have been made less threatening, and more feasible, by having had mindfulness be “religiously neutralized” through the cultural prominence of its secular variants and interpretations. All major religious traditions have changed over time, sometimes through influences—acknowledged or unacknowledged—from other traditions. But needs for self-preservation put such interreligious influences in a special context—and hence, mindfulness being “neutralized” may have made its adoption into Judaism be less threatening. More broadly, Sandage and Stein (2025) noted that the mindfulness-Judaism relationship has been framed in at least three different ways by Jewish communities: Mindfulness has been viewed “through,” “and,” and “as” Judaism (Niculescu, 2020, p. 1). For understanding these three stances, Sandage and Stein (2025) offered thoughtful reflection on the possible role of minimization, one of the DMIC interreligious orientations. Their analysis encourages empathy for Judaism and other minority religious traditions, and an appreciation for the complex motivations and needs that may give rise to various interreligious stances. Importantly, however, from the standpoint of a public health agency or clinician, all three of these Judaic stances may arguably best be viewed as different forms of Judaism, towards which a public health agency should not adopt a stance of minimization, but rather, a stance of acceptance or adaptation.
These perspectives from Sandage and Stein (2025) and the DMIC model underscore the multitude of factors that may influence how different cultures and peoples engage with contemplative practices. Individuals can grow in intercontemplative competence by learning about such factors, but their learning will never be complete. Thus, Sandage and Stein (2025) have articulated an ongoing complementarity and productive tension between competence and humility—or, as they characterized it, a “dialectic of intercultural competence and intercultural humility.” This, too, seems a necessary foundational perspective for needed trainings in intercontemplative competence.
Four Worldview Dimensions Relevant to Training
Building on the perspectives of Sandage and Stein (2025), I wish to suggest four overall dimensions of worldview diversity that might usefully be addressed in training in intercontemplative or intercultural competence, perhaps using the DMIC (Morgan & Sandage, 2016), for instructors of mindfulness or other contemplative practices. These four proposed priority dimensions of inter-worldview diversity are listed in Table 1. Of course, such training should not focus solely or even primarily on these four dimensions, but should also foundationally sensitize trainees to important views of relevant religious traditions and contemplative practices (Goleman, 1988; Plante, 2010; Smith, 1991).
Table 1
Dimensions of inter-worldview diversity relevant to intercontemplative competence training, selected
No | Dimension | Prototypical Categories |
|---|---|---|
1 | Degree of ontological affirmation in the existence of higher realities | Belief / Non-belief |
2 | Diversity in degree of affirmation of the salvific power of other spiritual or religious traditions | Inclusivism / Exclusivism |
3 | Diversity in degree of principled commitment to solidarity (mutual respect) with other spiritual or religious traditions | Tolerance / Solidarity |
4 | Whether the spiritual goal of contemplative practice is viewed as a personal deity, an impersonal higher reality, or a transimpersonala reality capable of both personal and impersonal manifestations | Personal / Impersonal / Transimpersonala |
The first two of these four proposed priority dimensions—ontological affirmation of higher powers, and a religiously inclusive stance—have been substantially explicated in previous publications for health professionals. For example, as noted in the target article, Zinnbauer and Pargament (2000) have explicated in detail the four counselor orientations of rejectionism, exclusivism, constructivism, and pluralism, and their implications for the ability of counselors to assist clients of diverse worldviews.
The third dimension, principled commitment to solidarity with other traditions—even if one may doubt their salvific power—is relevant to multicultural administrative competencies and challenges (Axis A11). This dimension of worldview variability has received greater attention from sociologists and political scientists than from clinicians. For example, Stewart et al. (2020, p. 2) describe varying stances toward the “persistent and inevitable fact of deep diversity” in religious worldviews. They distinguish “banal appeals for peaceful coexistence” from a principled approach that they have formalized, based on an explicit commitment to “neighborly solidarity… a culture of engagement characterized by relationships of mutual respect and protection” (see also Beaman, 2017, on “deep equality”; Moyaert, 2013, on “interreligious solidarity,” p. 203).
Last but not least, traditional systems of meditation vary in whether they emphasize the spiritual goal of meditation as union with a personally involved deity (often emphasized in Abrahamic traditions) or with a more distant, abstract, or perhaps impersonally represented ground or state (e.g., nirvana in some Buddhism traditions, or Brahman in some Hindu paths). Impersonal representations may feel most congenial to many scientists, whose professional frameworks “bracket out” the possibility a personal God’s divine action in the world. Yet a high level of intercontemplative competence would be characterized by equal fluency in understanding and relating to each category of goal representation, as well as to a third category of goal representation: The view that higher realities are simultaneously personal and impersonal. Smart (1996) reports that such a “double-decker Divine” involving an “impersonal ultimate, and manifesting from it the personal Lord,” is “quite common in the history of religions” (p. 171; see also Schmidt-Leukel, 2003; Vroom, 2006; and for two eminent exemplars of the latter approach, see Gandhi et al., 1967, p. 70, on “the Law and the Law-giver rolled into one”; and Sri Ramakrishna on God as “both personal and impersonal, with and without form,” Maharaj, 2018, p. 1). Table 1 uses the term “transimpersonal,” repurposed from linguistics (Malchukov, 2008), to designate this third view as going beyond the perspective, common among scientists, that the world is ultimately governed solely by laws that are impersonal, rather than by something that surpasses the impersonal by being both impersonal and personal.
Bridging Concepts
Another topic mentioned by several commentators is bridging concepts: conceptual analogues of mindfulness in other traditions or worldviews. For example, Aldbyani (2025) identified Muraqabah as such an analogue in Islam, Henning et al. (2025) noted Dadirri as a parallel among Australian First Nations (see also Lavrencic et al., 2021), and Sandage and Stein (2025) noted a partial overlap with Jewish prayer tradition, which “has long insisted on the intention of personal attention and presence.”
Commentators also appropriately warned against overly hasty and indiscriminate assertions of equivalence, perhaps sometimes a form of motivated minimization in Sandage and Stein’s DMIC model. For example, Wang (2025) enumerated several religious adaptations of mindfulness for Christian audiences. He viewed them as having “validity as interreligious engagement and mutual learning,” and as “consistent with the values of the Christian faith.” Yet he also stated that a future area of “critical importance,” especially in psychology, will be “studying Christian contemplation and historic Christian contemplative practices in their own light”—and to this end he reviewed and articulated several major, characteristic, or distinctive themes in historical Christian contemplative literature.
In contrast, Knabb and Vazquez (2025), concerned with Christian communities, showed little interest in bridging concepts, possibly because they believe that secularized mindfulness in the West still retains its root religious influences, “especially its telos or purpose,” such as “awareness of the three marks of existence,” which when undisclosed “prevents clients from other religions from making informed decisions.” Knabb and Vazquez have therefore preferred to develop and test alternative contemplative practice interventions, “starting from scratch within an alternative religious system,” Christianity, for which they described an impressive and growing body of work. Similarly, Sutton (2025) noted, particularly regarding mindfulness in work organizations, that some ostensible bridging concepts may function poorly by “changing the nature of mindfulness itself and thereby be reducing” its potential for benefiting health.
Together, all of these observations by commentators suggest that bridging concepts may sometimes be useful in interventions, but the underlying resemblances are not equivalencies, and may vary greatly in the degree of actual similarity. Consequently, adapted interventions should be evaluated carefully in the light of such variability, and it may sometimes be more appropriate to develop an intervention analogue independently, “from scratch.”
Partnership and Administration
Few commentators directly addressed issues of administrative adaptation, which concerns the possible need to adapt the delivery of a mindfulness intervention to better match the local workforce, institutions, government frameworks, policies, or work culture (Oman, 2025, Axis A11). But some commentators mentioned the related issue of community partnership. In particular, Galante and Van Dam (2025) highlighted the importance of “engaging with the community first to listen to what they have to say about their problems or their needs, and how they think these could be addressed,” pointing to an extensive literature on involving communities from the inception of efforts, and warning that skipping such discussion risks a “fundamental mismatch” with community needs. They point out, correctly, that some communities may not possess interest in mindfulness interventions or adaptations. I agree very much with such cautions and emphases, which are needed in any complete discussion of public health implementation. Moreover, the issue is not solely a question of objectively assessing community interests—relationship-building and maintenance can be crucial in many settings. A memorable maxim that has received increasing attention is “nothing about us without us” (e.g., Albert et al., 2023), and the target article (Axis A7) noted that labor unions, for example, “sometimes remain reluctant to support health-related policies [that] were not developed in consultation with them.” The implementation framework offered later in this paper therefore explicitly mentions the importance of community interaction and support in its early phases (i.e., Phases 1 and 2). However, the optimal form for such needed relationality and interest-assessment may vary greatly between localities—such as between a large multicultural urban area, versus a small culturally homogeneous community in which public health workers are all long-time residents. The proposed implementation framework therefore does not prescribe a particular form for such foundational activities, but merely prescribes that they are the responsibility of a task force.
Branding
Branding, the last axis (A14) discussed in the target article, involves building a symbol or label for communicating with a target audience, such as the population to whom a public health campaign is directed. Branding was addressed by Knabb and Vazquez (2025), who expressed an opposition to using the term “mindfulness” as an alternate descriptor for Christian forms of meditation. In the branding literature, using alternate terms to describe the same product or idea is sometimes called co-branding (Oman, 2025). An example of co-branding would be a public health campaign that alternated in using “meditation” and “mindfulness” as terms to describe an intervention such as Christian meditation. Using the same pair of terms to jointly co-brand a group of interventions—such as MBSR, Christian meditation, and Islamic meditation—is called umbrella co-branding.
To facilitate clear and useful future discussion of branding, I want to make it clear that in the target article, and in this reply, the term “branding” is intended to refer to imaging and messaging that is directed to the public, especially to potential intervention participants. Such messaging is conceptually distinct from technical terminology and communication used between professionals in scholarly or scientific fields. Sometimes the slippage between how key terms are used in these distinct contexts can be substantial, but also well-established—a fact on the ground that must be navigated. Thus, Koenig (2008) has argued for using distinct definitions of spirituality in research versus clinical practice. Whereas he advocates a narrower use of “spirituality” as a technical term in health research, he argues that in clinical work, “health professionals must communicate in a language that is welcoming and supportive” (p. 353), and that spirituality is acceptable as a “vague term that patients can define for themselves” (p. 354). Similarly, a two-track approach has evolved historically for the term “mantra,” and Oman (2024b) has advocated that the longstanding technical usage of mantra as a sanctified phrase from a spiritual tradition should be maintained, although a colloquial usage (e.g., as any frequently repeated slogan) could be necessary and acceptable for some interactions with intervention recipients.
This target article’s section on branding was thus not intended to advocate any particular technical language to be used between scholars. Rather, the branding section’s focus was on branding as communication directed to the public. The section posed the question of how a public health campaign should employ terms such as “mindfulness” and “meditation.” It suggested that answers would likely vary “between programs, populations, and cultures.” The target article also quoted the branding literature in explaining that branding messages are embedded in a larger branding process that “cannot be understood as a mere communications campaign [but] represents a cultural process, performed in an interplay between art and business, production and consumption, images and stories, design and communication,” (Schroeder & Salzer-Mörling, 2006, pp. 1, 3) and that “neither managers nor consumers completely control branding processes—cultural codes constrain how brands work to produce meaning” (p. 3).
This provides important context for opposition expressed by Knabb and Vazquez (2025) to using “mindfulness” as an umbrella co-branding descriptor of multiple meditation-based interventions derived from traditions with different worldviews. In particular, they expressed concern that “co-branding mindfulness with alternate practices may lead to assumptions of deep-level [worldview] coherence between the practices rather than clarifying the important foundational [worldview] differences that exist.” This is an important and nontrivial concern that should be taken into account going forward. Perhaps the most concrete issue is to ensure that prospective intervention participants receive sufficiently detailed program descriptions, plus an informed consent process, that protects them from risks relating to worldview-incompatibility harms. Does the valid need to safeguard against such harm mean that public health campaigns, anywhere in the world, should avoid using “mindfulness” as an umbrella descriptor for meditative interventions springing from heterogeneous worldviews? Should such campaign usage be avoided despite much of the public having become accustomed to the word “mindfulness” being used in many different ways—ways that include the positive application by Christians of some of meanings of “mindfulness” to their own tradition (Bretherton et al., 2016; see also Schmidt-Leukel, 2003 on some Christian views asserting worldview compatibility)? Perhaps that is what Knabb and Vazquez wish to argue, but I do not feel qualified to forecast how their legitimate concern—arguably mitigatable at the levels of individual program description and intervention participation—will or should be weighted and balanced within the totality of health communication considerations. This totality of considerations must inevitably vary in its weighting and between localities, but will often include the mindfulness term’s wide recognizability, generally positive valence, and publicly recognized meanings associated especially with its attentional features (see Choi et al., 2021, p. 5; Haddock et al., 2022). Branding or co-branding that works well in some locations might be inadvisable or contraindicated in other contexts.
Implementation
Palitsky et al. (2025) pointed out the salience of the emerging field of implementation science, proposing that implementation science is “vital for the uptake of mindfulness into global public health efforts.” I appreciate their comment, and agree about the relevance of implementation science, as well as their related point that one should “begin thinking of implementation and adaptation needs from the early stages of intervention development.” For such purposes, however, a parallel field known as translational science may sometimes or often be the best fit for public health, as its literature is often better-attuned to conceptualizing and supporting crucial partnerships with community-based organizations. Implementation science also arose with a central emphasis on “evidence-based practices,” long criticized for narrow definitions of evidence (e.g., Berg, 2019; Cohen et al., 2004). While implementation science has been commended for helping expand the use of qualitative methodologies in healthcare research, critics express reservations that this methodological integration remains vulnerable to vested interests and to the “dominating tendencies of the evidence-based movement” (Boulton et al., 2020, p. 379), placing implementation science “at risk of spreading a normative positivist methodology” (p. 390; see also Younas, 2024).
Notwithstanding such drawbacks, both implementation science and translational science have their strengths, weaknesses, and accomplishments, and scholars and practitioners may often be well-advised to draw what is beneficial from each field, while leaving behind what is unhelpful. In that spirit, this paper’s final major section will use a framework from Meyers et al. (2012). This framework, a product of implementation science, will be used as a springboard to formulate a step-by-step procedure for integrating mindfulness into local or regional public health.
Fanning Out and Minding the Gaps
The preceding sections responded to commentaries and issues that the present author deemed most urgent or foundational for opening roads for motivated communities to appropriately and safely integrate mindfulness and meditative practices into public health. But the long-term strength and effectiveness of such efforts, and their feasibility for communities in diverse cultural and religious settings, will depend on various additional types of foundational work. Many facets of that additional work were noted in the target article’s subsections, which were designed to “be engaged on their own terms even though they are part of a larger framework” (Palitsky et al., 2025). Although gaps remain, several commentaries on the target article can function similarly—almost as additional sections in a collectively authored “encyclopedia” (Palitsky et al., 2025)—with each section focused on specific conceptual or cultural interface issues.
The commentary by Wang (2025), for example, spotlighted a globally large group that has been under-represented in mindfulness research: “diverse Christian communities and marginalized/underrepresented Christian groups, particularly in the Global South.” Wang observed that one subset of Christianity, Evangelical Christianity, has been over-represented in previous Christian reflections upon and adaptations of mindfulness. As he pointed out, one reason for this being a very important topic is that the Global South (especially Africa, Asia, Latin America) is now home to a majority of Christian adherents worldwide (about 61%).
Three other commentators also provided in-depth explorations concerning an Abrahamic tradition. Like Wang (2025), Knabb and Vazquez (2025) also focused on Christian groups, describing their US-based research program to develop meditation-based interventions for Christians—a type of intervention characterized in the target article as an “analogue” of MBPs. Aldbyani (2025) explicated practices in Islam that are analogous to mindfulness. And Sandage and Stein (2025) probed deeply into several different ways that mindfulness has been apprehended within Judaism, reflecting upon those diverse apprehensions in light of a developmental model of interreligious competence, as noted above.
Henning et al. (2025) also provided resources to support interreligious inclusiveness and competence. They identified teachings and practices viewed as analogous to mindfulness within diverse traditions. In addition to sections addressed each of the five so-called world religions—Christianity, Islam, Hinduism, Buddhism, Judaism—they also attended to “earth-based spirituality or animistic worldviews,” such as the practices of the Maori (tāngata whenua) of New Zealand, the Kogi of Columbia, and others.
Other commentaries also were largely dedicated to breaking new ground for enacting needed agendas. As described in the following paragraphs, these include conceptually focused commentaries on epidemiology by Levin (2025), on organizational psychology by Sutton (2025), and on design by Altay and Porter (2025), as well as a commentary on ethics by Berryman (2025) that was discussed extensively earlier.
In particular, Levin (2025) provided a primer on several key epidemiologic concepts and principles relevant to mindfulness research, needed for providing the mindfulness field with a solid epidemiologic foundation (target article, Axis A6). More generally, the commentary proposed an “epidemiology of mindfulness.” Many of his ideas might also be applied to developing an epidemiology of attentional health, a concept discussed below (next subsection).
Sutton (2025), writing from an organizational psychology perspective, articulated how her field can contribute to the integration of mindfulness into public health. She directed special attention to its uses for addressing attentional environments (Axis A8 in the target article) and equity (Axis A9). She also directed considerable attention to resilience (Axis A5), which has been conceptualized and studied in organizations at both individual and collective levels. Warning against allowing mindfulness to be conceptualized solely as an aid to resilience-building, she advocated ongoing commitment to prevention (Axis A2)—that those employing mindfulness should “focus on its utility in more upstream applications such as identifying and addressing the causes of crises and acting to prevent them.”
Altay and Porter (2025) offered a sustained reflection and detailed analysis of the relevance of professions, such as architecture and town planning, that are focused on the design of physical environments. Whereas the target article had evaluated 14 topics or “axes” for their incorporation within (i) public health and (ii) mindfulness, Altay and Porter (2025) extended this evaluation to include the relevance of each axis within (iii) physical environmental design. Their results are presented systematically in their Table 1, in columns parallel to the two earlier evaluations in the target article. The results reveal considerable overlap between environmental design and the other two fields, suggesting substantial three-way mutual compatibility.
How might this three-field compatibility be foregrounded in future efforts, and harnessed for the public good? From a public health perspective, the demonstrated resonance between mindfulness and environmental design suggests a broad-based potential complementarity as components of multi-level interventions (Axis A7): Whereas the mindfulness and contemplative practice field has its greatest current strength in supplying individual-level intervention components, the analysis by Altay and Porter (2025) supports the promise of the environmental design field for supplying important collective-level intervention components. But how should the overall joint objective of such a multi-level intervention be conceptualized? To galvanize maximal public and interprofessional support, such a joint objective should possess an intelligible operationalization at different social-ecological levels, and resonate well with most or all major stakeholder groups. At the present sociocultural moment, I submit that one of the strongest formulations of a joint-level objective might be to promote attentional health.
Minding a Gap in the Commentary: Attentional Health
“How can attentional health be usefully theorized at both the individual and population levels?” was one of the questions posed in the target article’s agenda for future work (Oman, 2025, Table 5, Q5). As noted earlier, Galante and Van Dam (2025) agreed with the target article’s suggestion that some current mindfulness measurement instruments could be beneficially reframed as assessing “facets of attentional health.” And based on discussions in this special issue, I am inclined to think that formulating a cross-disciplinary and cross-culturally resonant construct of attentional health might be one of the most useful foundations—possibly even a needed “critical path”—for integrating the positive contributions of mindfulness into public health.
Attempts to advance the formulation of such an attentional health construct, however, were not undertaken by any of us, and remain a gap. But a gap that should be minded. This section therefore offers a few reflections to inch us forward, however gradually, starting with individual-level conceptions.
First, definitions of mental health itself remain multiple and contested (e.g., Galderisi et al., 2015). Aspiring to formulate a universally endorsed novel definition of attentional health might therefore be unrealistic. Instead, perhaps the mental health definitional debates can offer clues about the definitional choices and dilemmas that may be encountered, and the possible implications of various choices.
Second, it may be useful to review multiple influential definitions of mental health, to see if any of them could offer insight or lead easily toward a useful attentional health formulation. Galderisi et al. (2015), for example, define mental health as including “the ability to pay attention” (p. 232). Their overall definition of mental health also encompasses multiple considerations such as one’s capacity to “function in social roles” and “recognize… one’s own emotions” (p. 232). Do their multiple considerations, and their overall framework, include clues about how to conceptualize attentional health?
Last but not least, one might examine mental health definitions for clues useful to formulating an attentional health understanding across multiple life stages, cultures, and walks of life, and in a manner that is flexible and not “one size fits all.” Compared to older definitions of mental health, newer definitions have set higher aspirations for such flexible generalizability, sometimes through employing ideas such as “dynamic state of internal equilibrium” (Galderisi et al., 2015, p. 231). Can such approaches offer insight about how to conceptualize attentional health in a manner that is meaningful, yet sufficiently flexible? Recent progress in defining mental health suggests that useful definitions of attentional health could be within reach.
Step-by-Step Framework for Integrating Contemplative Practices into Public Health
This second major section presents an initial 8-phase implementation framework to guide efforts to integrate mindfulness and contemplative practices into local or regional public health. The framework’s basic structure is adapted from a synthetic review by Meyers et al. (2012), who generated a generic framework summarized in Table 2. The new mindfulness-focused framework presented here reflects adaptations to the specific needs and tasks of the mindfulness field, and consideration of many issues raised by commentators. Not having received empirical testing or systematic review, this new framework should be regarded as preliminary. However, for clarity, the present article refers to it as the Public Health Implementation of Meditation and Mindfulness (PHIOMM) framework. It is hoped that this PHIOMM framework can suggest practical through-lines for groups and individuals in local communities to recognize such integration as feasible, and to undertake it, provided that such integration is indeed a good fit for local conditions. The PHIOMM name is not intended to signal advocacy of any particular choice for local branding, but was selected to yield a minimally cumbersome acronym that still signaled openness to multiple branding approaches (i.e., “meditation” was included in addition to “mindfulness”, but “contemplative practice” was avoided for conciseness). The framework’s eight phases are presented in Table 3.
Table 2
Phases and steps of the quality implementation framework (QIF, Meyers et al., 2012)
Phase | Steps |
|---|---|
1 | Initial considerations regarding the host setting Assessment strategies 1. Conducting a needs and resources assessment 2. Conducting a fit assessment 3. Conducting a capacity/readiness assessment Decisions about adaptation 4. Possibility for adaptation Capacity Building Strategies 5. Obtaining explicit buy-in from critical stakeholders and fostering a supportive community/organizational climate 6. Building general/organizational capacity 7. Staff recruitment/maintenance |
2 | Creating a structure for implementation Structural features for implementation 9. Creating implementation teams 10. Developing an implementation plan |
3 | Ongoing structure once implementation begins Ongoing implementation support strategies 11. Technical assistance/coaching/supervision 12. Process evaluation 13. Supportive feedback mechanism |
4 | Improve future applications 14. Learning from experience |
Table 3
The public health implementation framework for meditation and mindfulness framework for step-by-step local implementation
Phase | Tasks | Phase No. in QIF | |
|---|---|---|---|
1 | Create an official task force through efforts that are bottom-up (from citizens’ groups), top-down (e.g., from government agencies), or a combination; | – | |
2 | Task force identifies a preliminary proposed intervention and any needed deepera structural adaptations or analogues, by specifying (i) an ensemble of programs, (ii) target sectors, (iii) any collective-level components; | – | |
3 | Task force carefully evaluates the preliminary intervention’s local adequacy for (i) addressing useful purpose; (ii) fitting cultural conditions; (iii) matching local readiness to implement (resources, skills, motivation); ⇨ If inadequate, either quit, return to Phase 2 and undertake major revisions of the intervention, or attempt to address through adaptation in Phase 4 | QIF Ss 1–3 | |
4 | Task force considers need and forms plans for any additional adaptation, such as adaptations of surfacea structures; ⇨ If needed, return to Phase 3 to re-evaluate adequacy of fit | QIF S 4 | |
5 | Task force and/or public health or other relevant officials undertake needed capacity-building (obtaining explicit buy-in from staff and other key stakeholders; building capacity; recruiting staff; providing staff training); | QIF Ss 5–8 | |
6 | Create structure for implementation (QIF Phase 2); | QIF Ss 9–10 | |
7 | Maintain ongoing structure once implementation begins (QIF Phase 3); | QIF Ss 11–13 | |
8 | Improve future applications (QIF Phase 4) | QIF S 14 | |
Before explaining the individual PHIOMM phases, it should be noted that mindfulness, in comparison with many other public health interventions, offers special resources but also brings special challenges with regard to adaptation, one of the key steps identified in the framework by Meyers et al. (2012). To leverage these resources and respond to these challenges, the PHIOMM framework replaces that single step with multiple decision points, as described below.
Among the special resources available to the mindfulness-type interventions, as noted by the target article, is that “practices analogous to Buddhist mindfulness can be found across all major religious traditions, and… intervention programs based on non-Buddhist contemplative practices have often been viewed as analogues to modernized mindfulness programs” (Oman, 2025, Axis A11). But among the special challenges of mindfulness-type interventions is the lack of a unified or well-supported understanding of the intervention’s core causal processes or “active ingredients.” Indeed, as noted in the target article, little evidence indicates that “the components named by an evidence-based program developer” should be regarded a priori as the program’s actual functional core components (Blase & Fixsen, 2013, p. 6; see also discussion above and comments by Galante & Van Dam, 2025; Palitsky et al., 2025; Sedlmeier, 2025).
Importantly, one function of meditation is widely accepted as core: Decades ago, observers were already affirming “the effort to retrain attention” as a core ingredient and process of meditation—indeed, a “single invariant ingredient in the recipe… of every meditation system” (Goleman, 1988, pp. 107, 169; see also Oman, 2021). But beyond agreement on the centrality of attentional retraining, little scientific consensus exists about core mediators of causal effects from MBPs or other meditative interventions, despite widespread affirmation of beneficial health effects. At the present time, therefore, holistic judgements must rely on blending together the best available outcome evidence, process experience, and locally relevant theory, to identify an optimal ensemble of mindfulness/meditative analogues that is appropriate for meeting perceived local needs. Consequently, time may be required to form a local working consensus regarding what adaptations or analogues should be employed.
The PHIOMM framework thus teases apart the process of identifying, discussing, and selecting “adaptations” into two stages, rather than a single step. The larger, arguably more fundamental adaptation task is placed in Phase 2, in which those initiating the implementation are asked to identify a particular ensemble of “mindfulness” or contemplative practice interventions, broadly construed. Such an ensemble might include only a single program. Or it might encompass programs that include MBSR-style MBPs as well as analogues such as Christian meditation, Buddhist meditation (especially relevant to localities where substantial Buddhist populations are present, e.g., Wu et al., 2019), or various other forms of Abrahamic, Dharmic, or other religiously rooted meditative practices. Openness to employing contemplative practice interventions from multiple traditions is part of what has been called an expanded-hub approach (Palitsky et al., 2025).
Phases of the PHIOMM Framework
Phase 1
The PHIOMM framework’s first phase recognizes that local interest may emerge in multiple ways. Interest in integrating contemplative practices into public health may potentially emerge either “top-down” from regional or national initiatives or policies, “bottom-up” from local conversations among community stakeholders such as concerned citizens and civic leaders, or through a combination of top-down and bottom-up influences. At some point, such local interest may reach a critical mass needed to generate a group, such as a task force, that is recognized by local community officials, and is officially or informally mandated to seriously explore the feasibility and desirability of integration. Importantly, to maximize prospects for successful implementation in the public interest, such a local task force should involve, or in some way be in close consultation, with members from important stakeholder groups, typically including not only public health professionals as well as one or more mindfulness and contemplative practice experts, but also local civic leaders, including local faith communities (Albert et al., 2023). It may also be desirable or essential to include or closely consult with representatives from sectors that may be engaged by the intervention (e.g., healthcare, education, workplace organizations and unions). In some localities—especially in the “global south”—representation of indigenous healing professionals may be highly desirable or essential.
Once such a task force is constituted, the phases identified in the Quality Implementation Framework (QIF) by Meyers et al. (2012) are helpful for envisioning what happens next. However, as noted earlier, to accommodate distinctive challenges of the mindfulness field (including the issues raised by commentaries), the first QIF phase has been separated into three separate phases, numbered 3 to 5 in the PHIOMM framework, with allowance made for cycling through one of these phases multiple times.
Phase 2
In the PHIOMM framework, the task force begins its work by formulating an initial (preliminary) vision for the specific programmatic and policy contents of the integration initiative, addressing questions that include:
(i)
What ensemble of programs and practices will be included? For example, will mindfulness-based programs such as MBSR be included? Will analogues be included such as Christian meditation (Knabb & Vazquez, 2025; Wang, 2025), Islamic practices (Aldbyani, 2025), Jewish practices (Sandage & Stein, 2025), mantram repetition (Oman & Driskill, 2003; Oman et al., 2022; Oman, 2024b), other recent adaptations that may use mantram repetition (Bringmann et al., 2021; Waelde, 2022), or interventions that explicitly retain substantial Buddhist content (Wu et al., 2019)?
(ii)
Into what sectors will integration of these programs be supported (e.g., healthcare, education, workplaces)?
(iii)
How will levels beyond the individual be addressed (if at all)? More specifically, what initiatives or policies are proposed for improving social (collective-level) attentional environments through supporting better workplace procedures, communication media, built environments, or other environmental features (e.g., Altay & Porter, 2025; Balboni & Balboni, 2018)?
As the present article goes to press, there are few published accounts of local integration efforts. Until more experience is available, it may therefore be prudent that local integration efforts, especially in larger communities, should consider beginning on a modest scale, perhaps targeting only a single sector and a single level. Additional sectors or levels could be flagged for future consideration. Over time, it might be possible to foster a “community of practice” in which pioneering local integration efforts share their experiences and learnings, without anyone inappropriately asserting authoritative expertise (Gunawardena et al., 2009; Lave & Wenger, 1991; Li et al., 2009). Uses and potentials of communities of practice have been discussed both in relation to specific fields such as mindfulness (Hwang et al., 2021), public health (Barbour et al., 2018; Meagher-Stewart et al., 2012), and healthcare (McLoughlin et al., 2018; Ranmuthugala et al., 2011), as well as for partnerships between providers of modern and traditional medicine, which may also benefit from being conceptualized as a community of practice (Thirthalli et al., 2016).
Phase 3
Once an initial specification of ensemble, sector, and level is identified, the PHIOMM framework asks the task force to engage in what the QIF calls the “assessment strategies” that comprise the QIF’s Steps 1 through 3: “conducting a needs and resources assessment,” “conducting a fit assessment,” and “conducting a capacity/readiness assessment” (Meyers et al., 2012, p. 469). Questions to be considered at this stage include “What problems or conditions will the innovation address?” (e.g., what are the intended benefits, and the theoretical and evidential basis for believing that the intervention will provide those benefits?), “how well does the innovation match the cultural preferences of… the organization/community?” and “to what degree does the organization have the will and means… to implement the innovation?” (p. 469; see Meyers et al., 2012, for the full set of questions). In this phase, consideration of several issues from the target article and commentaries would be appropriate—for example:
(i)
Is there a sufficiently strong case for the likelihood of public health benefits (note that different communities may give varying weight to varying types of evidence ranging from scientific to indigenous worldviews and healing philosophies)? What benefits are anticipated at the individual level (e.g., due to direct program participation), and what benefits are anticipated at the collective level (e.g., through policy-induced or programmatic spillover improvements in social environments)?
(ii)
Do anticipated intervention benefits outweigh the risks of individual adverse events (e.g., commentaries by Farias and Berryman), and how can such risks be minimized?
(iii)
Do anticipated intervention benefits outweigh any misfit with the local religious culture that risks generating adverse sociocultural or spiritual side effects (e.g., fostering a spiritual “monoculture” by implicitly denigrating pre-existing local traditions)?
(iv)
Are intervention benefits likely to outweigh any tendency to generate an overly individualistic framing of organizational or community problems (e.g., target article, Axis A8; comments by Farias; Palitsky et al.)?
(v)
Beyond religion, does the intervention ensemble pose any other tensions with local culture that might produce obstacles or benefit from proactive adaptation?
(vi)
To what extent does the community possess “the will and the means” (Meyers et al., 2012, p. 469) to appropriately staff each program in the intervention’s proposed ensemble? Are there local intervention instructors whose qualifications are supported by certification (e.g., for MBSR), experience in train-the-trainer instruction (e.g., Mantram Repetition Program, Buttner et al., 2016), experience in teaching relevant contemplative practices (e.g., instructors of Christian, Muslim, or other forms of meditation), or willingness to undertake needed training as well as any additional lifestyle commitments, if not already engaged in the practices (see Kabat-Zinn, 2003)? What are the sources and time requirements for attaining any needed training?
Concerns, suggestions, and other relevant input should also be obtained from community stakeholders, from health and human service staff, and from those likely to be delivering mindfulness or contemplative practice programs.
Phase 4
After the proposed intervention ensemble has been assessed in Phase 3 as potentially feasible, sufficiently promising, and a reasonably adequate fit for the community, the need for any additional forms of adaptation—especially so-called “surface structure” adaptation—should be evaluated and planned (this corresponds to QIF Step 4). The adaptational work here contrasts with the PHIOMM’s Phase 2 adaptational work, in which the task force made choices about using analogues or “deep-structure” adaptations (e.g., deep adaptations that involve “core cultural values” or sociohistorical factors, Resnicow et al., 1999, p. 12). The present Phase 4 focuses on additional potential adaptation, especially so-called “surface structure” modifications related to “matching intervention materials and messages to observable… ‘superficial’…characteristics of a population” (p. 10), such as language, locations, or the cultural identities of those delivering the intervention. As in Phase 3, concerns and other input should be sought from diverse stakeholders.
Also in this phase, it would seem desirable to finalize a system for matching or referring individuals to programs, if more than one program is offered (e.g., Christian meditation and MBSR; or, as described in the target article’s discussion of Axis A11, Passage Meditation—a program involving meditating on sacred texts from any tradition—and MBSR).
Phase 5
In the PHIOMM’s fifth phase, the task force and their backers obtain “explicit buy-in from critical stakeholders,” undertake other forms of capacity-building, and seek to foster a supportive community or organizational climate (Meyers et al., 2012, p. 469, QIF Step 5). As commitments are obtained, the intervention effort leadership may shift, expanding beyond or supplanting the task force. Subsequent steps during this phase, as recommended in the QIF, include “building general/organizational capacity” (QIF Step 6), “Staff recruitment/ maintenance” (QIF Step 7), and “effective pre-innovation staff training” (QIF Step 8) (Meyers et al., 2012, p. 469). At this time, the intervention leaders should put in place the instructional leadership capacity for each program.
Phase 6
Activating the intervention in real time requires what Meyers et al. (2012) call “creating a structure for implementation” (p. 470), the second overall phase of the QIF. It involves the steps of “creating implementation teams” (QIF Step 9), and “developing an implementation plan” (QIF Step 10).
Phase 7
“Ongoing structure once implementation begins” is the QIF’s next phase (Meyers et al., 2012, p. 470). Its three steps include “technical assistance/ coaching/ supervision” (QIF Step 11), “process evaluation” (QIF Step 12), and “supportive feedback mechanism” (QIF Step 13). Examples of questions to be addressed include how to “provide the necessary technical assistance to help the organization/community and practitioners deal with the inevitable practical problems that will develop once the innovation begins,” and how to “evaluate the relative strengths and limitations in the innovation’s implementation as it unfolds over time” (p. 470). Such questions have been considered to some degree in the broader mindfulness field, including MBPs and the Mantram Repetition Program (Buttner et al., 2016), and some of those procedures could be considered for adaptation to other programs.
Phase 8
This final PHIOMM phase, modeled on the final QIF phase, involves “improving future applications” (Meyers et al., 2012, p. 470). Its single step is “learning from experience” (QIF Step 14), and responds to questions such as “What lessons have been learned about implementing this innovation that we can share with others who have an interest in its use?” Because efforts to formally integrate mindfulness into public health are still in their infancy, every published account of an integration effort, regardless of its degree of success, would seem useful to the very wide base of individuals and communities potentially interested in pursuing integration, as reflected in the diverse sources of the commentaries in this special issue. Such reports would also be invaluable for creating refined versions of the present implementation protocol.
Using the PHIOMM Framework
The PHIOMM framework may be used in several ways. Even in its current preliminary form, the PHIOMM framework can be used for implementation, for reporting, and for research. And as described above, the PHIOMM may be used by concerned parties in diverse localities, not only in the USA or other wealthy countries, but perhaps many other communities worldwide, to guide integration of mindfulness or contemplative practices into health systems and health promotion.
Importantly, anyone intending to use the complete PHIOMM should obtain the explication of the QIF by Meyers et al. (2012). This is because the PHIOMM framework was adapted from the QIF, and relies upon it textually, for full explication of all of the PHIOMM’s steps and phases.
Once such integration efforts have been undertaken—with or without guidance by the PHIOMM framework—it could be very helpful for an account of these efforts to be published, or at least informally shared in some manner, as a guide to subsequent efforts elsewhere. Reports could very helpfully address questions that include: What steps were taken? What was accomplished during the implementation? What were the biggest challenges, and did they align with the challenges anticipated by the PHIOMM (and QIF)? How were the challenges addressed? Did the sequencing of work correspond with the PHIOMM’s phases, or did it occur in some other order? Meyers et al. (2012, especially p. 476) also offer a list of questions relevant to writing useful reports. In part through such sharing such reports, a community of practice can potentially emerge, providing needed peer support to implementation task forces in diverse settings (Barbour et al., 2018; McLoughlin et al., 2018; Meagher-Stewart et al., 2012).
Conclusion
This has been a reply to commentary on the target article, “Mindfulness for Global Public Health: Critical Analysis and Agenda” (Oman, 2025). I am grateful to the distinguished commentators who have helped advance my thinking on several important issues, including moderators, suitability for children, safety, mediators of causal effects, ethics, religious adaptations, community partnership, branding, and attentional health. Composing this reply has been gratifying, and also sometimes surprising. In composing responses in each of the areas just listed, I usually began by drafting direct responses to commentators. But to properly explain those responses, I usually felt compelled to articulate additional background, which sometimes brought into view additional insights and affordances for needed integrative advances. This reply thus eventually emerged as a mixture—I hope useful—of interdisciplinary and conceptual background, ideas newly formed or expressed, and replies to commentators.
Regarding the many rich ideas that emerged in the discussion, one key insight in my view is the suggestion by commentators that the mindfulness field can be significantly strengthened by situating it more firmly in the wider field of the study of contemplative practices, a suggestion with which I have concurred. Seeking to be practical, the present reply culminated by presenting an implementation framework that attempted to take into account the insights of the commentators, and that I hope can be useful to communities everywhere who view mindfulness or other contemplative practices as potentially relevant to their health. Fully and appropriately integrating contemplative practices into public health, however, is certain to be a prolonged process—as Hippocrates said, Ars longa, vita brevis (Art is long, life is short, as translated in Oman, 2021, p. 41). But a good time to begin such integration is the present moment.
Acknowledgements
I am indebted to Lynn Waelde for suggesting the construction of a framework for integrating mindfulness into public health, as done in the penultimate section of this manuscript.
Declarations
Conflict of Interest
The author declares no competing interests.
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