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. 2026 Mar 5;42(2):e70161. doi: 10.1002/smi.70161

Examining the Effectiveness of Breathwork to Improve Resilience and Psychological Wellbeing While Reducing Anxiety, Depression, Stress, and Insomnia in Paramedicine Students: A Single‐Blind Randomised Controlled Trial

Abbie Little 1,✉, Matthew Stainer 1, Alex (Sandy) MacQuarrie 2, Nicola Wiseman 1, Brian Haskins 3
PMCID: PMC12963692  PMID: 41787752

ABSTRACT

Paramedicine students experience disproportionately high rates of anxiety, depression, stress, and insomnia compared to the general population, placing them at risk of post‐traumatic stress disorder and long‐term psychological distress. Breathwork has emerged as a promising self‐regulation intervention that may enhance resilience and wellbeing while reducing symptoms of mental illness. This randomised controlled trial (RCT) evaluated the effectiveness of the A52 Breath Method, a structured breathwork protocol, in improving mental health and resilience among student paramedics. A single‐blind parallel‐group mixed‐methods RCT was conducted with 98 student paramedics from two Australian universities, randomised to either a 12‐week breathwork intervention or control, with results interpreted in light of differential attrition. The intervention involved twice‐daily practice of slow, diaphragmatic breathing (5‐s inhale, 5‐s exhale, 2‐s hold) with video and guided audio instruction. Outcomes included changes in anxiety, depression, stress (DASS‐21), insomnia (ISI), resilience (RS‐14), and psychological wellbeing (RPWB‐18), between baseline and post‐intervention. Analyses included 2 × 2 mixed factorial ANOVA, ANCOVA for baseline differences, and correlation analyses. At post‐intervention, participants in the breathwork group reported significantly lower stress, anxiety, and depression scores, and higher resilience compared to controls (all p < 0.05), with medium to large effect sizes. Insomnia and psychological wellbeing showed non‐significant changes. Qualitative feedback highlighted perceived benefits for self‐regulation, including emotional regulation and perceived psychological safety and control–although challenges to practice engagement was noted. The A52 Breath Method significantly reduced reported symptoms of psychological distress and enhanced resilience in student paramedics, even during exam stress. Breathwork shows promise as a scalable, upstream intervention to support mental health in paramedic student training.

Trial registration

Registered with the Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN12625000101482 on 30/01/2025. Available at: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=388884&showOriginal=true&isReview=true

Keywords: breathwork, emergency responders, mental health, psychological wellbeing, resilience, stress, student paramedics

1. Introduction

Paramedics and paramedicine students work in an everchanging, fast‐paced, and challenging environments that places them at increased risk of poor mental health. The nature of paramedicine includes frequent exposure to potentially traumatic incidents, physical exhaustion, irregular shifts, and abuse. The literature consistently highlights the concerningly high rates of post‐traumatic stress disorder (PTSD), anxiety, depression, stress, insomnia, and suicide experienced by paramedics, particularly post‐COVID‐19 (Alanazi et al. 2025; Ebben et al. 2023; Padmanabhanunni and Pretorius 2025; Vanjari et al. 2024). Moreover, paramedics are facing increasing levels of chronic burnout driven by overwhelming workloads, poor working conditions (organisational factors), occupational stress, and lack of support, contributing to the increased number of paramedics leaving the emergency medical profession (Middleton et al. 2025). Although research has focused on qualified paramedics, there is increasing concern regarding students entering clinical placements within a profession characterized by high occupational stress and variable levels of support (Alzahrani et al. 2025). Exploratory work in paramedicine students showed, with caution, that students had moderate‐severe levels of stress, anxiety, and depression symptoms, along with subthreshold to clinical insomnia (A. Little and Boyle 2025).

During undergraduate training and clinical placement, paramedicine students are exposed to acute academic demands alongside high‐pressure clinical environments often for the first time. Warren‐James et al. (2021) found that students on ambulance placements report elevated stress due to performance anxiety, fear of mistakes, vicarious trauma, and feelings of helplessness. A recent metanalysis based on 13 studies (n = 1064) in paramedic students found high pooled prevalence rates of PTSD, anxiety, and depression to be 17.9%, 56.4%, and 34.7% respectively (Alzahrani et al. 2025). In contrast, the general population reports much lower figures: anxiety (4.4%), depression (4.0%) (World Health Organization 2025), and PTSD (3.9%) (World Health Organization 2024). Sending students who may have high levels of psychological distress into a high stress profession may increase long‐term psychological distress and early career burnout. A low‐risk, cost‐effective intervention that provides paramedicine students with the tools to increase psychological wellbeing and resilience before they reach the workforce should be a critical priority for universities and state services.

Recently there has been growing interest in self‐regulation interventions–defined as strategies enabling individuals to regulate their thoughts, emotions, and physiological states (Karoly 1993)–that support mental health through influencing the autonomic nervous system (ANS). The ANS is considered a division of the peripheral nervous system that regulates involuntary physiological functions such as heart rate (HR), blood pressure, and respiration (Stanković et al. 2021). It comprises two main branches: the sympathetic nervous system (SNS) responsible for the fight‐or‐flight via the sympatho‐adreno‐medullary system and generally increases HR, and the parasympathetic nervous system (PNS) which promotes rest and digestion while generally decreasing HR. Optimal health relies on a dynamic balance between these systems, where dysregulation can be linked to stress and psychological distress (Goldstein 2021; S. Porges 2025; Thayer et al. 2009).

Within this context, breathwork–deliberately altering the way one breathes–has gained significant empirical attention regarding its psychophysiological effects (Banushi et al. 2023; Fincham et al. 2023; A. L. Little 2025; Zaccaro et al. 2018). Breathwork refers to the intentional regulation of breathing patterns to influence the nervous system, such as engaging the diaphragm rather than the upper chest (diaphragmatic breathing), adjusting respiratory rate, or modifying the route of airflow. Originating from ancient practices such as yogic pranayama, certain breathing techniques can have a significant impact on mental and psychological wellbeing and might be helpful in reducing stress (Fincham et al. 2023; A. L. Little 2025). In particular, the use of controlled breathing techniques has been found to be effective in reducing symptoms of anxiety, PTSD, panic disorder, depression, stress, and insomnia, conditions all increasingly found in paramedics (Banushi et al. 2023; Bonn et al. 1984; Brown et al. 2013; Chandla et al. 2013; Ma et al. 2017; Seppälä et al. 2014). Moreover, breathwork may reduce physiological and psychological stress as measured by decreased sympathetic activity; increased heart rate variability (HRV) and vagal tone, and decreased blood pressure, respiration, cortisol levels, and self‐report of psychological wellness, for instance using the DASS‐21 scale (Hopper et al. 2019; Siebieszuk et al. 2025).

Emerging evidence suggests that slow, intentional breathing can influence the autonomic nervous system through vagal pathways, where activation of the vagus nerve regulates HR through respiratory sinus arrhythmia (RSA) and contributes to fluctuations in HRV, cortisol, and emotional states (S. W. Porges 1995a, 2007; Sevoz‐Couche and Laborde 2022). Breathwork has also shown psychophysiological improvements mediated from both the “top down” (e.g., frontal cortex) and “bottom up” (e.g., physiological autonomic processes and hypothalamic‐pituitary‐adrenal (HPA) axis) (Wahbeh et al. 2016). However breathing techniques vary widely in ratios, duration, pacing, and delivery method, making it hard to distinguish which techniques are the most effective (A. L. Little 2025; Siebieszuk et al. 2025). To address this gap, the current study examines the effectiveness of a structured breathwork protocol, the A52 Breath Method, in improving mental health outcomes in paramedicine students. This method is based on existing literature surrounding slow‐paced, nasal, and diaphragmatic breathing, and aims to engage the parasympathetic nervous system to reduce psychological distress (Dada et al. 2024; Daniel‐Watanabe et al. 2025; Jung et al. 2024; Luo et al. 2025; Pozzato et al. 2025). The A52 Breath Method is a structured variation of slow‐paced breathing practices, involving a 5‐s nasal inhalation, 5‐s nasal or mouth exhalation, and a 2‐s post‐exhalation hold – repeated for 10 min to achieve five‐breaths‐per‐minute (see Figure 1). This pace aligns with established techniques such as coherent or resonant breathing, which have been associated with increased HRV, vagus nerve activation, decreased cortisol levels, and improved emotion regulation (Chin and Kales 2019; Dada et al. 2024; Saito et al. 2024). These psychophysiological effects reflect how slow breathing reduces sympathetic activity and enhances parasympathetic activity, shifting the ANS towards regulation and recovery.

FIGURE 1.

FIGURE 1

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A diagram outlining the A52 Breath Method.

The A52 Breath Method is grounded in scientific principles including the Bohr effect, vagal tone stimulation, and baroreflex engagement through diaphragmatic innervation (Benner et al. 2018; A. L. Little 2025). Breath retention post‐exhalation has been shown to increase lung capacity and cause a vasodilating effect while increasing self‐regulation, high frequency‐heart rate variability (HF‐HRV; a marker of parasympathetic activity and vagal tone), and vagal nerve stimulation (Hakked et al. 2017; Russell et al. 2017).

Diaphragmatic breathing is considered to influence autonomic regulation through mechanisms such as the Hering‐Breuer reflex, where lung inhalation activates pulmonary stretch receptors that signal via vagal afferent fibers to brainstem respiratory centers, inhibiting excessive inspiratory drive and supporting parasympathetic dominance (D. J. Noble and Hochman 2019). Nerve signals then ascend via the 10th cranial nerve, the vagus nerve, to the brainstem and signals expiration (Gard et al. 2014). Slow breathing may also enhance baroreflex sensitivity, contributing to increased vagal tone and reduced sympathetic arousal (Siebieszuk et al. 2025). Increased baroreceptor stimulation may alter the reticular activating system, which is a network of neurons located in the brainstem and hypothalamus, which are responsible for controlling fight or flight (sympathetic nervous system), sleep, and waking responses (Garcia‐Rill 2015; Goldstein 2021). When practiced regularly, breathwork may act as a protective buffer against psychological distress (Fincham et al. 2023).

Informed by polyvagal theory (Porges 1995b) and neurovisceral integration theory (Thayer and Lane 2000), this pragmatic RCT evaluates whether the A52 Breath Method over 12 weeks leads to measurable improvements in anxiety, depression, insomnia, stress, resilience, and psychological wellbeing. We hypothesise that breathwork participants will subjectively report significant improvement in stress, anxiety, depression, insomnia, resilience, and psychological wellbeing compared to the control group. In addition to quantitative outcomes, qualitative feedback will be collected to explore participants' perceptions of the A52 Breath Method, including its acceptability, perceived benefits, and challenges to practice engagement. This study aims to examine a scientifically sound method which may enhance paramedic student resilience and psychological wellbeing while providing an upstream approach which may prevent and attenuate depression, anxiety, insomnia, and stress.

1.1. Research Question

Does the A52 breathwork intervention significantly reduce symptoms of stress, anxiety, depression, and insomnia, and improve psychological wellbeing and resilience in student paramedics compared to a control group over a 3‐month period?

2. Methods

2.1. Study Design

This study employed a single‐blind, two‐arm, parallel‐group, pragmatic RCT design to examine the effect of the A52 Breath Method on anxiety, depression, insomnia, stress, psychological wellbeing, and resilience in student paramedics. The study was conducted over a 12‐week period and included pre‐ and post‐intervention questionnaires. The study adhered to CONSORT guidelines for reporting RCTs and was prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12625000101482). Ethical approval was obtained from Griffith University's Human Research Ethics Committee (GUHREC2024/767). All investigations were conducted after obtaining informed consent.

2.2. Participants, Setting, and Recruitment

Participants were eligible if they were: (1) enroled in a paramedicine degree at Victoria University or Monash University, (2) in their second year or above, (3) aged 18 years or older, (4) fluent in English, and (5) able to commit to the 12‐week study schedule. Participants were excluded if they had prior experience with breathwork training or if they disclosed a diagnosis of a serious psychiatric condition such as schizophrenia or bipolar disorder, or active use of illicit drugs.

A priori sample size was calculated using G*Power Version 3.1.9.7 with a medium effect size (d = 0.25), α = 0.05, power of 0.8, and two groups (Heinrich‐Heine‐Universität Düsseldorf, Düsseldorf, Germany). A conservative small‐moderate effect size was selected a priori to detect meaningful differences in a new remotely delivered breathwork intervention between groups. This equated to 34 participants (17 per group). To allow for incomplete data and dropouts, the recruitment target was increased. A total of 98 participants completed the baseline assessment and were randomised, with 42 controls and 24 breathwork participants completing the trial due to differential attrition.

Recruitment occurred in early 2025 through university mailing lists, video and in‐person presentations, and flyers. A total of 147 expressions of interest were received via an online Qualtrics survey which also ascertained informed consent to participate. Of these, 98 participants (49 breathwork and 49 controls) completed the full baseline questionnaire and were included in the trial (see Figure 2). In the breathwork group, 18 were lost to follow‐up for the following reasons: 15 did not complete the trial‐exit questionnaire, one withdrew due to personal issues, one no longer wished to participate, and one sustained an injury outside of the study that prevented them from participating. In the control group, seven were lost to follow‐up with six not completing the trial exit questionnaire and one withdrawing due to personal reasons. In the breathwork group, participants who reported intervention adherence at 20% or below were evaluated using their qualitative responses to determine whether they engaged meaningfully with the A52 breath method (e.g., describing usage, technique‐specific engagement, or situational application). Inclusion was not based on perceived benefit, but on evidence that the method was attempted or used. Those reporting 0% practice frequency were excluded from the study. A total of 24 in the breathwork group and 42 in the control group were included in the final analysis. Upon follow‐up, participants from both universities were within end of semester examination periods.

FIGURE 2.

FIGURE 2

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CONSORT flow diagram.

2.3. Randomization, Allocation, and Blinding

Participants were randomly allocated to either the breathwork intervention group or the control group using a simple randomization procedure. A random allocation sequence was generated prior to data collection using an online random list generator that alternated “control” and “intervention” group assignments. As eligible participants completed the baseline survey, they were sequentially assigned to the next allocation on the list in the order they entered the study. This method is consistent with pre‐generated random allocation sequence assignment using fixed randomization without blocking or stratification. Participants were aware of their group allocation due to the nature of the intervention; however, investigators were blinded to group allocation during data analysis to reduce bias.

2.4. Intervention

Following completion of the baseline questionnaire, those allocated to the intervention group received access to the A52 Breath Method. This slow, diaphragmatic technique consisting of a 5‐s nasal inhalation, 5‐s exhalation, and a 2‐s post‐exhalation breath hold, performed for 10 min twice daily, was designed to downregulate paramedic students' nervous system. Within 24 h of completing the questionnaire, participants were emailed a 30‐min pre‐recorded instruction video created by an Australian breathwork instructor with over 10 years of experience who has trained more than 1000 instructors. The video discussed the rationale, structure, and correct technique. They also received a 10‐min guided audio track to use during each session. A follow‐up text message reminder was sent 1 month into the study, encouraging participants to keep practicing. Due to the nature of rolling recruitment, the exact start date of the 12‐week intervention period was staggered from 14 March 2025 to 31 March 2025 based on when each participant completed the baseline assessment.

2.5. Control

Participants in the control group were instructed to continue with their usual activities and had access to university mental health and wellbeing resources, including counseling services and student support programs. No additional materials or interventions were provided during the 12‐week study period. Control group participants were offered access to the breathwork materials after the completion of the study.

2.6. Outcome Measures

All participants completed identical questionnaires at baseline and post‐intervention (after 12 weeks). The survey included several demographic questions along with the following validated and reliable instruments to measure key mental health and resilience outcomes.

  • Depression, Anxiety and Stress Scale – 21 items (DASS‐21): A 21‐item scale for measuring levels of depression, anxiety, and stress with good reliability (α = 0.81–0.89) (Coker et al. 2018; Ng et al. 2007; Oei et al. 2013; Osman et al. 2012). In the current sample, internal consistency was acceptable, with Cronbach's alpha values of 0.82 for the depression subscale, 0.78 for stress, and 0.75 for anxiety.

  • Insomnia Severity Index (ISI): A 7‐item scale evaluating the severity, nature, and consequences of insomnia (α = 0.83) (Bastien et al. 2001; Cerri et al. 2023; Morin 1993). Internal consistency in the present sample was good (Cronbach's α = 0.87).

  • Ryff's Psychological Well‐Being Scale – 18 items (RPWB‐18): An 18‐item validated scale (α > 0.70) (Klainin‐Yobas et al. 2020) measuring six dimensions of wellbeing: self‐acceptance (a positive attitude towards oneself), positive relations (satisfying relationships with others), autonomy (self‐determination and independence), purpose in life (having meaningful goals), environmental mastery (ability to manage one's life), and personal growth (openness to new experiences and ongoing development) (C. D. Ryff 1989; C. D. K. C. L. Ryff and Keyes 1995). Internal consistency in the present sample was good (Cronbach's α = 0.82).

  • Resilience Scale – 14 items (RS‐14): A reliable 14‐item measure of trait resilience (α = 0.80–0.90), being an individual's capacity to withstand and recover from stress, capturing self‐reliance, purpose, perseverance, equanimity, and existential aloneness (Aiena et al. 2015; Pritzker and Minter 2014; Wagnild and Young 1993). Internal consistency in the present sample was good (Cronbach's α = 0.89).

In addition to quantitative measures, a single open‐ended question was presented at post‐intervention to all participants: “Following your intervention or control participation, tell us about your experience in as much detail as possible. For instance, comment on your personal improvements mentally, physically, emotionally, or lack thereof, as well as anything else of note.” This qualitative data aimed to provide subjective insight into participant experiences with or without the intervention.

2.7. Analysis

Data were stored securely in programs, which required institutional login with multi‐factor authentication, and in password‐protected files on the researcher's computer. Access was restricted to Griffith University ethics requirements. The survey data was exported from Qualtrics into jamovi (Statistical Software Version 2.6.44, The jamovi project, Sydney, Australia) for cleaning and analysis. Normality was assessed using skewness and kurtosis (± 3). For those data meeting normality, descriptive statistics (means, standard deviations (SD), frequencies) were used to analyze demographic data. Prevalence rates of mental illness were noted.

To assess intervention effectiveness, 2 × 2 mixed factorial ANOVA tests were used, with group (breathwork vs. control) as the between‐subject factor and time (pre vs. post) as the within‐subject factor. Simple effects analyses were used to assess significant interactions. For outcomes where statistically significant baseline differences were observed, data were analyzed using ANCOVA to control for between‐group differences, and paired samples t‐test to explore within‐group changes. Effect sizes (partial η2 (η2 p)) and 95% confidence internals (CI) were reported alongside p‐values, where significance was set as p < 0.05. Additionally, Pearson correlation analyses were conducted on change scores (post – pre) to examine if improvements in resilience and psychological wellbeing were associated with reductions in stress, anxiety, depression, and insomnia.

Qualitative responses were analyzed using reflexive thematic analysis (Braun and Clarke 2006, 2019). Analysis followed the six‐phase process described by Braun and Clarke, including: familiarization, generating initial codes, searching for themes, reviewing themes, defining themes, and producing selective illustrative quotations. Data were initially coded by one researcher and then reviewed collaboratively with a second, non‐bias researcher, to enhance coding reliability and reflexivity. Reflexivity was addressed by considering how researcher positioning could influence qualitative interpretation, including the potential for a positively oriented analytic lens. Reflexivity was actively used throughout the qualitative analysis through repeated cycles of data familiarisations and critical reflection, along with discussion between co‐authors during coding and theme development to broaden perspective. The technique of peer debriefing was undertaken during coding and theme development with a co‐author experienced in qualitative research and not directly involved in the intervention, enabling critical examination of potential assumptions (H. Noble and Smith 2015). Member checking was also incorporated, whereby preliminary coding and themes were presented to peers for feedback and were revised with diverse perspectives as familiarity deepened (Dahal 2025). As recommended by Braun and Clarke (2019), themes were treated as actively generated ideas from patterns of shared meaning united by a central organizing concept, rather than already pre‐existing in the data. The reflexive process enhanced analytical transparency and supported theoretically informed interpretation of participants' experiences.

3. Results

3.1. Baseline Characteristics

The baseline characteristics from this RCT are presented in Table 1. A total of 98 student paramedics were enroled in this study and randomly allocated to the control (n = 49) or intervention group (n = 49). Age was not normally distributed in either group (Shapiro–Wilk p < 0.001; skewness = 2.62, kurtosis = 8.34 in the breathwork group) therefore, a non‐parametric Mann–Whitney U test was conducted. Categorical variables were tested with chi‐squared tests. There were no significant differences between the breathwork and control groups in age (U = 1003, p = 0.158), gender (χ2(2) = 1.10, p = 0.578), study year (χ2(2) = 1.13, p = 0.567), ethnicity (χ2(10) = 8.21, p = 0.609), or marital status (χ2(5) = 2.53, p = 0.771).

TABLE 1.

Baseline participant characteristics by group.

Variable Total (n = 98) Control (n = 49) Intervention (n = 49) Test p‐value
Age (years; median (range)) 23 (19–64) 22 (19–41) 23 (19–64) U = 1003 0.158
Gender χ2(2) = 1.10 0.578
Female 56 (57.1%) 27 (55.1%) 29 (59.2%)
Male 41 (41.8%) 21 (42.9%) 20 (40.8%)
Non‐binary 1 (1.0%) 1 (2.0%) (0) 0%
Ethnicity χ2(10) = 8.21 0.609
Caucasian Australian 69 (70.4%) 36 (73.5%) 33 (67.3%)
South‐East Asian 13 (13.3%) 6 (12.2%) 7 (14.3%)
Southern and Eastern European 6 (6.1%) 2 (4.1%) 4 (8.2%)
Indian 3 (3.1%) 1 (2.0%) 2 (4.1%)
Caucasian new Zealander 1 (1.0%) 0 (0%) 1 (2.0%)
Australian/Middle Eastern 1 (1.0%) 1 (2.0%) 0 (0%)
North‐West European 1 (1.0%) 1 (2.0%) 0 (0%)
Pacific Islander/Tongan 1 (1.0%) 1 (2.0%) 0 (0%)
Southern and central Asian 1 (1.0%) 1 (2.0%) 0 (0%)
Caucasian South African 1 (1.0%) 0 (0%) 1 (2.0%)
South American 1 (1.0%) 0 (0%) 1 (2.0%)
Marital status χ2(5) = 2.53 0.771
Single 70 (71.4%) 34 (69.4%) 36 (73.5%)
Defacto 16 (16.3%) 8 (16.3%) 8 (16.3%)
Married 7 (7.1%) 4 (8.2%) 3 (6.1%)
Prefer not to say 3 (3.1%) 1 (2.0%) 2 (4.1%)
Divorced 1 (1.0%) 1 (2.0%) 0 (0%)
Separated 1 (1.0%) 1 (2.0%) 0 (0%)
Study year χ2(2) = 1.13 0.567
Second year 34 (34.7%) 18 (36.7%) 16 (32.7%)
Third year 63 (64.3% 31 (63.3%) 32 (65.3%)
Postgraduate 1 (1.0%) 0 (0%) 1 (2.0%)
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Note: Values are presented as n (%) unless otherwise specified. Age is reported as median (range). χ2 = chi‐square test; U = Mann–Whitney U test. No significant differences were observed between groups on any baseline characteristics (all p > 0.05).

At baseline, all measured outcomes were normally distributed (all +/−3 in skewness and kurtosis). Independent samples t‐tests indicated no significant differences between the breathwork and control groups across anxiety, depression, stress, insomnia, and resilience (all p > 0.123). A small but statistically significant difference was observed in psychological wellbeing (t(96) = 2.10, p = 0.039, d = 0.42), with slightly higher scores in the breathwork group.

3.2. Prevalence of Mental Health Symptoms at Baseline

At baseline, elevated levels of anxiety (63.3%), stress (42.9%), and depression (43.9%) were observed, defined as individual DASS‐21 scores ≥ mild. Moreover, 23.5% of the sample reported moderate‐to‐severe insomnia. These findings highlight notably high rates of psychological distress within student paramedics prior to the intervention. At baseline, Pearson correlation analysis revealed that higher levels of resilience and psychological wellbeing were significantly associated with lower levels of anxiety, depression, stress, and insomnia (all r ≥ 0.30, all p ≤ 0.004). These observations reinforce the theoretical rationale for targeting resilience and wellbeing in the current intervention.

3.3. Analyses of Primary Outcomes

Notably, during post‐intervention data collection, students were within their end of semester university exams and practical objective structured clinical examinations (OSCEs)–a time typically associated with increased academic stress. To examine the changes within and between subjects over time, 2 × 2 mixed factorial ANOVAs were conducted for each outcome– except for psychological wellbeing which was analyzed using ANCOVA to account for the significant baseline differences. Results are shown in Figure 3 and Table 2. Simple effects analyses were used to assess significant interactions (see Table 3).

FIGURE 3.

FIGURE 3

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Estimated marginal means of psychological outcomes pre‐ and post‐intervention for breathwork and control groups. Panels show results for: (A) Stress, (B) Anxiety, (C) Depression, (D) Insomnia, (E) Resilience, and (F) Psychological Wellbeing. Blue lines represent the breathwork group; orange lines represent the control group. Panels A–E are based on repeated measures ANOVA with time (pre vs. post) as the within‐subjects factor and group as the between‐subjects factor. Psychological Wellbeing (Panel F) is plotted as adjusted post‐intervention estimated marginal means, controlling for baseline wellbeing scores (ANCOVA model), due to significant baseline group differences.

TABLE 2.

Results of 2 × 2 mixed factorial ANOVAs for mental health outcomes and ANCOVA for psychological wellbeing controlling for baseline scores.

Outcome Within‐subjects effect (Time) Between‐subjects effect (Group) Interaction (Time × Group)
Stress F(1, 64) = 0.13, p = 0.717, η2 p = 0.002 F(1, 64) = 8.42, p = 0.005, η2 p = 0.116 F(1, 64) = 12.88, p < 0.001, η2 p = 0.167
Anxiety F(1, 64) = 2.52, p = 0.117, η2 p = 0.055 F(1, 64) = 7.96, p = 0.006, η2 p = 0.111 F(1, 64) = 3.70, p = 0.059, η2 p = 0.055
Depression F(1, 64) = 1.93, p = 0.169, η2 p = 0.029 F(1, 64) = 8.56, p = 0.005, η2 p = 0.118 F(1, 64) = 2.95, p = 0.091, η2 p = 0.044
Insomnia F(1, 64) = 0.00, p = 0.946, η2 p < 0.001 F(1, 64) = 2.07, p = 0.155, η2 p = 0.031 F(1, 64) = 1.13, p = 0.291, η2 p = 0.017
Resilience F(1, 64) = 0.33, p = 0.569, η2 p = 0.005 F(1, 64) = 4.45, p = 0.039, η2 p = 0.065 F(1, 64) = 1.43, p = 0.237, η2 p = 0.022
Psychological wellbeing (ANCOVA*) No significant effect F(1, 63) = 1.28, p = 0.263*, η2 p = 0.020 No significant effect
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Note: Mixed factorial ANOVAs assessed within‐subjects effects of time (pre‐to post‐intervention), between‐subjects effects of group (breathwork vs. control), and their interaction on each outcome. Psychological wellbeing was analyzed using mixed factorial ANCOVA to adjust for baseline differences. η2 p = partial η2 and is reported as the effect size. p < 0.05 is considered statistically significant. *ANCOVA = Analysis of covariance controlling for baseline psychological wellbeing score.

TABLE 3.

Simple effects summary for psychological outcomes pre‐ and post‐intervention in breathwork and control groups.

Outcome Effect type Comparison condition Estimated mean difference (Post ‐ Pre or Group diff) 95% CI t df p
Stress Change over time (within) Breathwork group −1.08 [–2.46, 0.30] −1.55 81.1 0.124
Control group 1.18 [0.01, 2.35] 2.01 62.1 0.048 *
Group difference at timepoint Pre 0.02 [–1.46, 1.50] 0.03 150 0.98
Post 2.28 [0.64, 3.91] 2.75 158 0.007 **
Anxiety Change over time (within) Breathwork group −1.21 [–2.55, 0.13] −1.80 81.2 0.075
Control group −0.11 [–1.23, 1.02] −0.19 63.5 0.851
Group difference at timepoint Pre 0.83 [–0.66, 2.32] 1.1 148 0.273
Post 1.94 [0.29, 3.58] 2.33 158 0.021 *
Depression Change over time (within) Breathwork group −0.29 [–1.67, 1.08] −0.42 82.6 0.674
Control group 0.06 [–1.11, 1.23] 0.1 62.7 0.922
Group difference at timepoint Pre 1.29 [–0.15, 2.73] 1.78 151 0.078
Post 1.64 [0.04, 3.24] 2.03 159 0.044 *
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Note: Bolded values indicate statistically significant results.

*

p < 0.05.

**

p < 0.01.

3.3.1. Stress

Considering the increased stress associated with the exam period, there was a significant between‐subjects effect of group on stress scores, F(1,64) = 8.42, p = 0.005, η2 p = 0.116, with overall stress being lower in the breathwork condition. No significant main effect of time was found. A significant time × group interaction was found for stress F(1,64) = 12.88, p < 0.001, η2 p = 0.167, demonstrating that the breathwork and control groups changed differently over time (Figure 3A).

Simple effects showed that stress significantly increased within the control group from pre‐to post‐intervention as they approached exam time, t(62.1) = 2.01, p = 0.048, whereas the breathwork group showed a non‐significant decrease t(81.1) = −1.55, p = 0.124. At post‐test, a significant between‐group difference was observed, t(158) = 2.75, p = 0.007, with lower stress in the breathwork group.

3.3.2. Anxiety

A significant main effect of group was found, F(1,64) = 7.96, p = 0.006, η2 p = 0.111, with lower anxiety in the breathwork group overall. No significant main effect of time was observed. The time × group interaction almost reached significance (F(1,64) = 3.70, p = 0.059, η2 p = 0.055).

Follow‐up comparisons indicated that at post‐test, anxiety scores were significantly lower in the breathwork group compared to controls, t(158) = 2.33, p = 0.021. The breathwork group decreased anxiety symptoms over the 3‐month period and approached significance (p = 0.075).

3.3.3. Depression

A significant main effect of group was found, F(1,64) = 8.56, p = 0.005, η2 p = 0.118, with lower depression in the breathwork group overall. No significant main effect of time or interaction was observed.

Post‐test comparisons revealed a significant between‐group difference, t(159) = 2.03, p = 0.044, with lower depression scores in the breathwork group. No significant within‐group changes were detected.

3.3.4. Resilience

A significant main effect of group was found, F(1,64) = 4.45, p = 0.039, η2 p = 0.065, indicating higher resilience in the breathwork group compared to controls. No significant effect of time or interaction was observed.

3.3.5. Psychological Wellbeing

An ANCOVA adjusting for baseline differences revealed no significant between‐group effect, F(1,63) = 1.28, p = 0.263, partial η 2 = 0.020 (Table 2). No significant within‐group changes were detected. Descriptive trends (Figure 3F) indicated higher adjusted post‐intervention scores in the breathwork group relative to the control group. To further explore within‐group changes, paired samples t‐test were conducted separately for each group. Results showed no significant change in psychological wellbeing from pre‐to post‐intervention in either the breathwork group or control group.

3.3.6. Insomnia

No significant between‐group effect was found, F(1,64) = 2.07, p = 0.155. Likewise, no main effect of time or interaction emerged.

3.4. Correlation Among Change Scores

Pearson correlation analyses were conducted to explore the relationships among changes in psychological outcomes from pre‐to post‐intervention as shown in Figure 4. Strong positive correlations were observed between changes in stress, anxiety, and depression, indicating that participants who improved in one mental health domain, tended to improve in others. Specifically, change in stress was strongly correlated with change in anxiety (r = 0.668, p < 0.001) and depression (r = 0.603, p < 0.001), and moderately with insomnia (r = 0.350, p = 0.004).

FIGURE 4.

FIGURE 4

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Pearson correlations between change scores (post‐intervention).

Changes in resilience were moderately negatively correlated with changes in stress (r = −0.276, p = 0.025), depression (r = −0.403, p < 0.001), and insomnia (r = −0.420, p < 0.001), suggesting that improvements in resilience were associated with reductions in psychological distress. Similarly, psychological wellbeing change scores were positively associated with improvements in resilience (r = 0.524, p < 0.001) and negatively associated with depression (r = −0.325, p = 0.008) and insomnia (r = −0.371, p = 0.002).

3.5. Qualitative Feedback

Qualitative feedback was analyzed using reflexive thematic analysis. In the intervention group, the following two main themes were actively generated via the researchers' interpretive engagement with the data (Braun and Clarke 2019): self‐regulation and challenges to practice engagement. Within self‐regulation, two sub‐themes were created: emotional regulation and perceived psychological safety & control. In the control group, the theme of absence of change and escalating stress was generated. The themes, description, and illustrative quotation are displayed in Table 4.

TABLE 4.

Qualitative themes and illustrative participant quotes.

Theme Sub‐themes Description Quote
Self‐regulation Emotional regulation Participants described using breathwork to regulate emotional responses during and following stressful experiences, supporting restoration of calm, emotional clarity, and the ability to process stressors more adaptively.

– “The main difference I noticed… was an increased feeling of calm and mental clarity after each session. This was especially helpful on nights I was stressed studying for an exam or an osce (like tonight) ‐ it helps me relax and calm down, helping me to focus on studying, and also helps relax me before I go to bed, so that I'm not trying to go to sleep stressed after studying. During placement, doing breathwork after shifts helped me to relax and also process some tough jobs we went to as well instead of just pushing those feelings to the back of my mind. This breathwork technique with the provided audio is something I will continue to practice as I've noticed the overall benefits and calming effects.”

– “I found that the intervention was useful as it allowed me to relax and wind down, which was beneficial mentally and emotionally.”

– “I felt like I grew resilience in hard times because I could remind myself of good things while doing my breath work. I Felt like I became more in touch with my emotions and didn't feel out of control. I Feel like I have a stronger sense of balance and peace in my well‐being.”

– “I have definitely found the breath work helps my to calm down during heightened emotional experiences.”
Perceived psychological Satefy & control Participants described a sense of reassurance and safety derived from knowing they had access to a breathwork technique, which functioned as a supportive coping resource in anticipation of stressful situations and provided confidence in their ability to manage distress if it arose.

– “The (A52 breath method) has become part of my coping tool kit”

– “I felt relieved knowing that i always had this technique in my pocket to use”

– “I felt as if I had more control… despite missing some days of the study”
Challenges to practice Participants identified barriers to consistent breathwork engagement, including time constraints, difficulty integrating the practice into daily routines, and reliance on reminders or structured support to maintain adherence.

– “I really struggled to make the deep breathing a daily habit… the few times I did do it in the day it was good, but I couldn't make myself organize the 10 min to do it each day.”

– “Wouldn't adopt this technique as it's time consuming and wouldn't find a way to fit it in my day. During high stress scenarios I did find myself adopt the technique but only for as long as it took me to calm down, didn't take too long.”

– “The breathwork was very rewarding when I found the time to do it. Enabled better mental clarity and calm. However I found it hard to integrate into daily routine and was difficult without consistent reminders or robust ways to integrate it into routine. Will keep using as much as I can.”
Control group: Absence of change and escalating stress Control group participants reported little to no perceived change in wellbeing over the study period, with some describing ongoing or increasing stress in response to academic and placement demands.

– “I was in the control group and had a friend in the intervention group and comparing the two of us, she seemed much more positive during exams and placement and much more relaxed as a whole. I Felt stressed and often would become quite anxious during placements due to fear of doing something wrong.”

– “Nothing has really changed after being in the control group”

– There has been a lack on personal improvements, due to stress of university assignments and exams recently.
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3.5.1. Self‐Regulation

Participants described the A52 Breath Method as a self‐regulation tool that supported their capacity to manage internal emotional and physiological states, particularly during periods of heightened stress. Across accounts, breathwork facilitated emotional regulation and fostered a sense of psychological safety and perceived control. Reductions in perceived stress were commonly described as outcomes of these self‐regulatory processes.

3.5.1.1. Emotional Regulation

Participants found that the breathwork technique was a useful tool in the process of regulating emotional responses and restoring calm during and following periods of heightened stress and overwhelm. Emotional regulation was most frequently cited, particularly in relation to exam stress and emotionally challenging placements. One participant noted they “found a significant difference for the better in (their) ability to overcome things that sometimes would make (them) anxious as well as (their) reactions to things”. These findings coincide with the quantitative results where the A52 Breath Method statistically lowered stress, anxiety, and depression at post‐test compared to the controls whose scores increased.

3.5.1.2. Perceived Psychological Safety and Control

The subtheme–perceived psychological safety and control–describes how the breathwork technique fostered a sense of confidence and safety in an anticipatory and supportive manner, even when not actively used. Several participants commonly described the breathwork as a valuable tool that acted as a coping resource in anticipation of stressful situations and for unwinding after high‐pressure scenarios and traumatic on‐road jobs. Participants shared that they felt “relieved” knowing they had this tool in their “pocket to use”, with one participant explaining, “I felt as if I had more control… despite missing some days of the study”. Another student explained “the (A52 Breath Method) has become part of my coping tool kit”. The breathwork technique helped to provide confidence in the practitioner's ability to manage distress if it arose.

3.5.2. Challenges to Practice Engagement

Some challenges limited consistent engagement with the intervention. Despite positive effects, several individuals noted barriers to consistent breathwork practice, citing issues such as time constraints, low motivation, or difficulty in routine integration without “reminders”. The statements made by the participants highlight important consideration for implementation in real‐world settings, where participants may benefit from prompts, in person instruction, or support in routine integration.

3.5.3. Control Group: Absence of Change and Escalating Stress

The control group reported both absence of change and escalating stress over the course of the trial period. One participant stated, “I was in the control group and had a friend in the intervention group and comparing the two of us, she seemed much more positive during exams and placement and much more relaxed as a whole. I felt stressed and often would become quite anxious during placements due to fear of doing something wrong.”

4. Discussion

This randomised controlled study examined the effects of a structured breathwork intervention, the A52 Breath Method, on the mental health and wellbeing of paramedicine students. The current study found that over half of participants initially reported above normal levels of anxiety (63.3%), and nearly half of participants reported concerning levels of stress (42.9%) and depression (43.9%). Additionally, 23.5% reported moderate‐to‐severe insomnia. These rates reflect a substantial baseline burden of psychological symptoms in student paramedics, even before entering the workforce.

Significant between‐group differences were observed for stress, anxiety, depression and resilience scores. The most interesting result was the reduction in stress within the breathwork group compared to a significant increase in the control group. This was supported by a significant time × group interaction and large effect size (F(1,64) = 12.88, p < 0.001, η2 p = 0.167), suggesting a potential protective effect of the A52 Breath Method. Students in the intervention group did not exhibit the same decline in mental health scores observed in the control group across the study period. These patterns may reflect the timing of post‐testing, which coincided with the university exam period. This may have contributed to the increase of stress in the control group, whereas the breathwork group appeared buffered from this deterioration in stress.

These findings contribute empirical evidence to the growing body of literature examining the potential role of the A52 Breath Method in buffering against acute academic stress and enhance psychological resilience in paramedicine students. Furthermore, implementing such interventions upstream, during training or early career stages, may delay or mitigate the onset of mental health symptoms in high‐risk emergency responder populations. This aligns with the literature which suggests that resilience‐building and stress‐management interventions delivered early can buffer against later psychological distress (Joyce et al. 2019; Robertson et al. 2015; Selak et al. 2024; Wild et al. 2020).

Although within‐group changes did not consistently reach statistical significance, simple effects analyses indicated lower post‐intervention scores in the breathwork group compared to controls across measured mental health outcomes. This supports prior findings that breathwork may positively modulate the autonomic nervous system and promote parasympathetic activation, leading to reduced stress, anxiety, and depression (Dada et al. 2024; de Wit and Moraes Cruz 2021; A. L. Little 2025; Pozzato et al. 2025; Zaccaro et al. 2022). This is further supported by the qualitative responses, where the themes generated indicate that breathwork participants experienced increased self‐regulation, with several participants stating they experienced increased mental clarity, peace, calmness.

In contrast, while trending positively for the intervention group, changes in insomnia and psychological wellbeing did not reach statistical significance compared to the controls. This may be due to the stressful end of semester exam time‐period in which the post‐intervention results were collected. Narrative responses suggest perceived benefits in mental stability, stating that despite increasing stress and traumatic situations, the breathwork helped manage anxious emotions and improve falling asleep, while acting as a “coping tool” to promote psychological safety. According to S. Porges (2025), autonomic safety is the prerequisite for regulation and resilience.

As shown in Figure 3B–E, participants in the breathwork group reported improved mental health outcomes than the controls, regardless of timepoint. While within‐subject changes over time were not statistically significant, the pattern of post‐intervention differences suggests a potential protective effect of the A52 Breath Method during a period of heightened academic stress. Simple effects analyses (see Table 3) indicate that the A52 Breath Method was beneficial in buffering against worsening stress, anxiety, and depression during exam time.

Correlation analysis of change scores, such as change in stress, strongly correlated with changes in anxiety and depression, while resilience showed moderate inverse correlations with depression and insomnia, and strong correlations with psychological wellbeing. These associations support the internal validity of the intervention's effects across multiple domains and highlight the interconnected nature of stress, psychological distress, and protective factors like resilience and wellbeing.

We posed an open‐ended question to both the breathwork and control group. Qualitatively, the breathwork participants described the breathwork as a tool for self‐regulation, with two subthemes capturing key self‐regulatory processes: emotional regulation and perceived psychological safety and control. Participants described the breathwork as a tool they had “in their pocket to use” during periods of heightened stress. Even when not actively practiced, simply knowing that the technique was available appeared to foster a sense of reassurance and confidence. Participants reported that the breathwork became part of their “coping tool kit”, supporting their ability to manage anxiety, unwind after high‐pressure scenarios, and regulate emotional responses following demanding on‐road placements. According to Fonseca et al. (2021), perceived control over adversity is paramount to coping. As such, these subjective experiences align with the reductions observed in the stress, anxiety, and depression outcomes. The theme of self‐regulation aligns with theoretical models of diaphragmatic breathing, which propose that slow, controlled respiration is known to activate the vagus nerve and instil calm via parasympathetic innervation (Hopper et al. 2019; Ma et al. 2017; S. W. Porges 2022).

Participants also described that breathwork resulted in stress relief as an outcome of emotional regulation, often characterizing the practice as creating “peace in (their) wellbeing”, awareness, and calm during difficulty. Students reported that breathwork enabled them to “grow resilience in hard times” and helped them to regulate stress, aligning with the observed correlations between resilience and reductions in stress, anxiety, depression, and insomnia. Emotional regulation emerged as the most frequently reported theme, particularly in relation to examination stress and emotionally demanding placements. Participants described increased mental clarity, improved ability to calm themselves, and greater capacity to process challenging experiences rather than suppress emotional responses–an essential regulatory capacity according to the polyvagal theory (S. Porges 2025). From this polyvagal perspective, the perception of safety is a prerequisite for adaptive engagement of the parasympathetic nervous system, facilitating calm states that support emotional regulation and social engagement (S. W. Porges 1995b, 2022). Similarly, the neurovisceral integration theory states that the capacity to regulate emotions is underpinned by a dynamic interplay between central and autonomic neural systems, enabling flexible physiological and behavioral responses to stress (Thayer et al. 2009; Thayer and Lane 2000). Within these frameworks, slow, controlled breathing may act as an accessible bottom‐up mechanism that enhances vagal regulation and self‐regulatory capacity.

Qualitative responses from the control group highlighted absence of changes or increased stress over the trial period. One control participant mentioned she was anxious and fearful of making a mistake on paramedic placement, an established stressor within paramedic training that has been consistently reported in existing literature (Warren‐James et al. 2021). Overall, the written responses suggest that the A52 Breath Method's perceived usefulness in both acute and chronic stress contexts, reinforces its potential applicability in paramedicine. Despite these perceived benefits, a subset of participants touched on barriers to consistent engagement, including difficulty integrating practice into routine, forgetting to practice, and time constraints. These responses suggest that adherence and habit formation are key challenges. As reported by Winter et al. (2022), studies that use reminders only to encourage engagement result in less retention than active faciliatory led interventions. Using breathwork instructors to lead practitioners either in person or directly online may support adherence.

However, while live instruction and observation may optimize breathing technique and individual benefit, such approaches can limit scalability. These findings suggest that a brief, remotely delivered breathwork intervention may be effective in supporting stress regulation among paramedicine students and perhaps broader emergency responder training. Nevertheless, the challenge of balancing individualized guidance with scalable delivery is vital to the development and promotion of breathwork interventions. Embedding short breathwork modules into curriculum, with some manner of hybrid constructive observation, may provide a proactive approach to stress resilience that is potentially cost‐effective and easily disseminated. We recommend future economic analysis to confirm cost‐effectiveness. Given the high rates of mental health symptoms reported in this study and in the paramedic profession, early exposure to self‐regulation tools may shape healthier psychological habits. Additionally, providing reminders, group sessions, or integrating app‐based delivery could support engagement.

Overall, the results from quantitative and qualitative findings suggest that breathwork may be a simple and effective intervention, which even when delivered remotely, may mitigate psychological distress in paramedicine students. Moreover, the results from this study suggest that the A52 Breath Method could potentially serve as a protective tool during known high‐risk periods, such as placements, exams, or during exposure to trauma in the field.

4.1. Strengths, Limitations and Future Directions

A strength of this study is in the randomised controlled design with both quantitative and qualitative data collection from two different institutions. This mixed‐methods approach enabled a deeper understanding of both the measurable outcomes and experiences associated with the intervention. Paramedicine students represent a population exposed to high occupational stressors, and early, supportive interventions during training could influence stress mitigation over time. By targeting students before entering the workforce, this study supports an upstream prevention approach.

Limitations of the study include its final sample size including differential attrition, while sufficiently powered, was modest and results should be interpreted accordingly. The open‐ended question may have benefited from being split into two to avoid any potential positive reporting bias. Adherence to the breathwork protocol was self‐reported and objective measures were not used, such as practice logs or biometric data. While video instruction increased deliverability, it should be noted that direct observation of how participants performed the breathing practice could therefore not be measured. Suboptimal breathing patterns, such as excessive effort, chest tension, or over‐breathing may reduce the calming effects of slow breathing practices and may explain the modest effects observed for outcomes such as psychological wellbeing or insomnia. Future studies incorporating guided instruction may be more beneficial.

Higher dropout rates were observed in the breathwork group, raising the possibility of attrition bias. Additionally, the intervention used the specific 5–5–2 breathing protocol. While the results support its feasibility and potential efficacy, the intervention is not compared with alternate breathing patterns or an active control group outside of standard access to university support services. Future research should examine how to optimize engagement, explore long‐term and short‐term effects with increased sample sizes, use objective measures such as HRV monitoring, use breathing comparison groups, and test intervention effectiveness during acutely stressful scenarios.

5. Conclusion

This randomised controlled trial contributes empirical support suggesting that a structured breathwork intervention, such as the A52 Breath Method, may help significantly mitigate psychological distress in student paramedics. Notably, the post‐test period coincided with university exams, a time of heightened stress, during which the control group showed increased distress while the breathwork group did not. Participants in the breathwork group reported lower post‐intervention levels of stress, anxiety, and depression compared to controls, with moderate to large effect sizes, and significantly higher levels of resilience. These findings were supported by qualitative responses highlighting the intervention's perceived benefits for self‐regulation.

The current study found paramedicine students reported concerning levels of anxiety, stress, depression, and insomnia. This coupled with rising mental health challenges in paramedicine, demonstrates the need for an upstream intervention that is effective and can serve as a tool to support resilience, wellbeing and long‐term psychological health. Future research should use larger sample sizes, objective measures such as HRV monitoring, and consider hybrid instruction to ensure correct practice.

Author Contributions

Abbie Little: conceptualization, methodology, data curation, formal analysis, investigation, project administration, writing – original draft, and writing – review and editing. Matthew Stainer: conceptualization, formal analysis, supervision, writing – review and editing. Alex (Sandy) MacQuarrie: conceptualization, writing – review and editing, supervision, resources. Nicola Wiseman: conceptualization, writing – review and editing, supervision, resources. Brian Haskins: conceptualization, writing – review and editing, supervision, project administration, resources.

Funding

The authors have nothing to report.

Ethics Statement

This study was approved by the Griffith University Human Research Ethics Committee, approval number 2024/767.

Consent

Informed consent was obtained electronically via Qualtrics following participants' review of the Participant Information and Consent Form (PICF).

Conflicts of Interest

The authors declare no conflicts of interest.

Acknowledgements

The authors wish to thank all participating paramedicine students for their valuable time and contributions to this study. They also would like to thank Victoria University and Monash University for their participation in the study and continued commitment to the wellbeing of paramedics. The authors gratefully acknowledge Johannes Egberts for his contributions to the field of breathwork and for his support in the digital representation, instruction, and communication of the A52 breathing rhythm. Declaration of Generative AI and AI‐Assisted Technologies in the Writing Process: During the preparation of this work, the author AL used AI to assist with non‐intellectual aspects of manuscript preparation. The use of this tool was confined to limited language support only. All intellectual content, study design, analysis, interpretation, and conclusions were generated and verified by the author. The author takes full responsibility for the integrity and originality of the work presented. Open access publishing facilitated by Griffith University, as part of the Wiley ‐ Griffith University agreement via the Council of Australasian University Librarians.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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