Experiential Avoidance in Primary Care Providers: Psychometric Properties of the Brazilian “Acceptance and Action Questionnaire” (AAQ-II) and Its Criterion Validity on Mood Disorder-Related Psychological Distress

Ci a ion: Be a-O e o, T.; Ba celó-Sole , A.; Mon e o-Ma in, J.; Maloney, S.; Pé ez-A anda, A.; López-Mon oyo, A.; Sal o, V.; Sussumu, M.; Ga cía-Campayo, J.; Dema zo, M. Expe ien ial A oidance in P ima y Ca e P o ide s: Psychome ic P ope ies o he B azilian “Accep ance and Ac ion Ques ionnai e” (AAQ-II) and I s C i e ion Validi y on Mood Diso de -Rela ed Psychological Dis ess. In . J. En i on. Res. Public Heal h 2023,20, 225. h ps://doi.o g/ 10.3390/ije ph20010225 Academic Edi o : Paul B. Tchounwou Recei ed: 31 Oc obe 2022 Re ised: 20 Decembe 2022 Accep ed: 21 Decembe 2022 Published: 23 Decembe 2022 Copy igh : © 2022 by he au ho s. Licensee MDPI, Basel, Swi ze land. This a icle is an open access a icle dis ibu ed unde he e ms and condi ions o he C ea i e Commons A ibu ion (CC BY) license (h ps:// c ea i ecommons.o g/licenses/by/ 4.0/). In e na ional Jou nal o En i onmen al Resea ch and Public Heal h A icle Expe ien ial A oidance in P ima y Ca e P o ide s: Psychome ic P ope ies o he B azilian “Accep ance and Ac ion Ques ionnai e” (AAQ-II) and I s C i e ion Validi y on Mood Diso de -Rela ed Psychological Dis ess Ta iana Be a-O e o 1,†, Albe o Ba celó-Sole 2,3,† , Jesus Mon e o-Ma in 4,5,6,* , Shannon Maloney 4, Ad ián Pé ez-A anda 2, Alba López-Mon oyo 7, Ve a Sal o 1, Ma cio Sussumu 1, Ja ie Ga cía-Campayo 2,3,8,9 and Ma celo Dema zo 1 1Cen o Men e Abe a (B azilian Cen e o Mind ulness and Heal h P omo ion), Depa men o P e en i e Medicine, UNIFESP, São Paulo 04753-060, B azil 2Ins i u e o Heal h Resea ch o A agon (IIS), 50009 Za agoza, Spain 3P ima y Ca e P e en ion and Heal h P omo ion Resea ch Ne wo k (RedIAPP), 28029 Mad id, Spain 4Depa men o Psychia y, Wa ne o d Hospi al, Uni e si y o Ox o d, Ox o d OX3 7JX, UK 5Teaching, Resea ch & Inno a ion Uni , Pa c Sani a i San Joan de Déu, 08830 San Boi de Llob ega , Spain 6Conso ium o Biomedical Resea ch in Epidemiology & Public Heal h (CIBER Epidemiology and Public Heal h—CIBERESP), 28029 Mad id, Spain 7 Depa men o Basic, Clinical Psychology, and Psychobiology, Uni e si a Jaume I, 12006 Cas ellón de la Plana, Spain 8Psychia ic Se ice, Hospi al Miguel Se e , 50009 Za agoza, Spain 9Depa men o Psychia y, Uni e si y o Za agoza, 50009 Za agoza, Spain *Co espondence: jesus.mon e [email p o ec ed] † These au ho s con ibu ed equally and can be conside ed as i s au ho s. Abs ac : Backg ound: A sizeable p opo ion o B azilian P ima y Ca e (PC) p o ide s su e om common men al diso de s, such as anxie y and dep ession. In an e o o cope wi h job- ela ed dis ess, PC wo ke s a e likely o implemen maladap i e s a egies such as expe ien ial a oidance (EA). The Accep ance and Ac ion Ques ionnai e (AAQ-II) is a widely used ins umen ha e alua es EA bu has shown ques ionable in e nal consis ency in speci ic popula ions. This s udy assesses he psychome ic p ope ies o he AAQ-II among B azilian PC p o ide s, e alua es i s con e gence and di e gence wi h sel -c i icism and mind ulness skills, and explo es i s c i e ion alidi y on anxie y and dep essi e symp oms. Me hods: A c oss-sec ional design was conduc ed in B azilian PC se ices, and he sample included 407 PC wo ke s. The measu es e alua ed EA, sel -c i icism, mind ulness, dep ession, and anxie y. Resul s: The one- ac o model o he AAQ-II eplica ed he o iginal e sion s uc u e. The AAQ-II p esen ed good in e nal consis ency among B azilian PC p o ide s. A mul iple eg ession model demons a ed highe ela ionships wi h sel -c i icism han mind ulness skills. The c i e ion alidi y o he AAQ-II on anxie y and dep ession was s onge in he con ex o mo e se e e symp oms. Conclusions: The AAQ-II is an app op ia e ques ionnai e o measu e he lack o psychological lexibili y among B azilian PC wo ke s in he sense o EA. Keywo ds: AAQ-II; p ima y ca e p o ide s; psychological lexibili y; expe ien ial a oidance; sel -c i icis m; mind ulness; anxie y; dep ession 1. In oduc ion Psychological lexibili y is associa ed wi h he abili y o pu sue alued goals despi e being in he p esence o oublesome expe iences [ 1 ]. This cons uc has been p oposed as a p ocess o change unde lying “Accep ance and Commi men The apy” (ACT) [ 2 ], which is a con ex ual he apy o med by p inciples such as accep ance, cogni i e de usion, alues- based ac i a ion, and pe sis ence. The p inciples o ACT wo k in unison o help inc ease he capaci y o adap o he ci cums ances o li e wi hou losing sigh o one’s alues and goals. In . J. En i on. Res. Public Heal h 2023,20, 225. h ps://doi.o g/10.3390/ije ph20010225 h ps://www.mdpi.com/jou nal/ije ph In . J. En i on. Res. Public Heal h 2023,20, 225 2 o 13 One o he mos widely used sel - epo ins umen s o assess psychological lexibili y is he “Accep ance and Ac ion Ques ionnai e” (AAQ-II) [ 3 ], which conside s accep ance and ac ion as key expe ien ial componen s. The AAQ-II includes se en i ems ha measu e expe ien ial a oidance (EA), which is used as an example o psychological in lexibili y. EA is ope a ionalized as he unwillingness o expe ience pain ul hough s and emo ions and is associa ed wi h he inabili y o be p esen and beha e acco ding o one’s alue-di ec ed ac ions [ 4 ]. I has been said ha EA may be implica ed in he e iology o a ious o ms o psychopa hology and ha eco e y o men al illness migh be media ed h ough educ ions in EA [ 5 ]. As men ioned abo e, his concep was o iginally de eloped wi hin he ACT amewo k. S ill, i seems o apply o o he o ms o “ hi d wa e” Cogni i e-Beha io al The apies (CBTs), such as “Dialec ical Beha io The apy” (DBT) [ 6 ] o “A achmen -Based Compassion The apy” (ABCT) [7], among o he s. The AAQ-II is he second i e a ion o he ques ionnai e. I was de eloped o o e come some psychome ic p oblems obse ed in he p e ious e sion ela ed o poo in e nal con- sis ency alues and an uns able ac o ial s uc u e [ 8 ]. Despi e he AAQ-II seeming o ha e o e come he lack o e inemen in ope a ionalizing EA, e en a e being ansla ed in o di e en languages, i s ill demons a es ques ionable in e nal consis ency alues in speci ic popula ions. Con en -speci ic e sions ha e been c ea ed o inc ease psychome ic p ope - ies in a ge popula ions and con ex s. Fo ins ance, some modi ied e sions o he AAQ-II ha e been adap ed o he wo kplace (Wo k- ela ed Accep ance and Ac ion Ques ionnai e, WAAQ) [ 9 ]; o adul s wi h hea ing loss (Accep ance and Ac ion Ques ionnai e-Adul Hea ing Loss (AAQ-AHL)) [ 10 ]; o indi iduals who a e o e weigh o obese (Food C a - ing Accep ance and Ac ion Ques ionnai e, FAAQ)) [ 11 , 12 ]; o adul s wi h ch onic pain (Accep ance and Ac ion Ques ionnai e II-pain e sion, AAQ-II-P) [ 13 ]; and ca diac pa- ien s (Ca dio ascula Disease Accep ance and Ac ion Ques ionnai e (CVD-AAQ)) [ 14 ]. A p e ious explo a o y s udy ha adap ed a Po uguese e sion o he AAQ-II, using a sample o B azilian college s uden s, p esen ed a unidimensional s uc u e o he AAQ-II wi h a gene al ac o ha ing p omising psychome ic p ope ies [ 15 ]. Howe e , his s udy had some me hodological sho comings. Fo example, his s udy only used explo a o y ac o ial analysis (EFA) and did no make use o con i ma o y ac o ial analysis (CFA). Mo eo e , his pape did no e alua e he i o he unidimensional model p oposed and did no p o ide in e nal consis ency es ima es acco ding o he mos ecen s anda ds. The ex e nal alidi y o his s udy was also limi ed due o he sample being es ic ed o college s uden s. The e o e, i is necessa y o ca y ou subsequen s udies, looking a speci ic a ge popula ion samples, using his adap ed e sion o he AAQ-II o help e alua e i s ac o ial alidi y in he B azilian popula ion. P ima y Ca e (PC) p o ide s cons i u e a speci ic a ge popula ion since hey a e highly a ec ed by job- ela ed mood-diso de psychological dis ess [ 16 ]. In B azil, i has been highligh ed ha 21% o PC wo ke s migh su e om common men al diso de s, such as anxie y and dep ession [ 17 ]. PC p o ide s could be using EA as an escape mechanism o cope wi h hei sense o lack o con ol o e s esso s in hei cu en wo king en i on- men s [ 18 ]. In ac , i has been p oposed ha , o example, EA is a signi ican p edic o o bu nou among psychology and nu sing unde g adua e s uden s [19]. Two o he a iables ha e been iden i ied as signi ican ly associa ed wi h dis ess and bu nou in simila popula ions: sel -c i icism and mind ulness [ 20 – 22 ]. Sel -c i icism, as he nega i e coun e pa o sel -compassion [ 21 ], can be conside ed a dys unc ional emo ion egula ion s a egy [ 23 , 24 ] used o deal wi h nega i e e en s in which one iews hei own mis akes as he cause o an e en [ 25 ]. On he o he hand, mind ulness e e s o a men al ai o s a e associa ed wi h inc eased awa eness o he p esen momen and cha ac e ized by a non-judgmen al a i ude. Pas esea ch has indica ed ha mind ulness skills a e associa ed wi h se e al indica o s o physical and psychological heal h [ 26 , 27 ]. Reducing sel -c i icism and imp o ing mind ulness skills may help p e en and educe psychological dis ess h ough he p ocess o b eaking pa e ns o eac i i y ha igge anxie y and dep ession, and he cycle o su e ing [ 28 ]. Bo h he p esence o sel -c i icism In . J. En i on. Res. Public Heal h 2023,20, 225 3 o 13 and he absence o mind ulness skills can be add essed h ough he p ac ice o medi a- i e exe cises ha p omo e a en ion o he p esen momen [ 29 ]. I has been obse ed ha mind ulness p ac ices, o example, in he con ex o mind ulness-based p og ams (MBPs), may imp o e anxie y, dep ession, psychological dis ess, and men al well-being in heal hca e p o essionals [ 30 ]. Mo eo e , pas wo k sugges s ha hese MBPs may imp o e ou comes h ough he media ing ole o EA, sel -c i icism, and mind ulness [ 31 ]. P e ious s udies ha e shown signi ican ela ionships be ween bu nou , EA, and sel -c i icism, as well as signi ican and nega i e ela ionships be ween bu nou and he p esence o mind ul- ness skills in heal hca e s uden s and p o essionals [ 19 , 22 ]. In gene al, sel -compassiona e a i udes (i.e., he opposi e o sel -c i ical a i udes) and mind ulness skills ha e been ound o be s ongly and nega i ely co ela ed wi h EA [32,33]. The main aim o he p esen s udy was o assess he psychome ic p ope ies o he AAQ-II in B azilian PC p o ide s using he B azilian e sion o he ques ionnai e ha was o iginally adap ed [15]. Addi ionally, he s udy e alua es i s con e gence and di e gence wi h espec o sel -c i icism and mind ulness and es ima es i s c i e ion alidi y on anxi- e y and dep essi e symp oms. We conside ed p e ious s udies ha ha e e alua ed EA, sel -c i icism, and mind ulness as common po en ial mechanisms in MBPs [ 34 ] and pas wo k ha has s udied he po en ial p o ec i e ole o mind ulness, sel -compassion, and psychological lexibili y on bu nou [ 19 , 22 ], which ela es o anxie y/dep essi e symp- oma ology [ 35 ]. Thus, we expec ed: (1) s ong posi i e ela ionships be ween EA and sel -c i icism; (2) s ong nega i e ela ionships be ween EA and mind ulness skills; and ( 3) s ong posi i e ela ionships be ween EA and anxie y and dep essi e symp oms. These explo a ions will help cla i y he ex en o which u u e esea ch on EA may help enable ac ions and imp o emen s in he well-being o PC wo ke s and imp o e he quali y o PC B azilian se ices. 2. Ma e ials and Me hods 2.1. Design, Pa icipan s, and P ocedu e A c oss-sec ional design was used wi h measu emen s ob ained using online sel - epo echniques. A sample o PC p o ide s om São Paulo, B azil, who we e employed be ween May and July 2015, we e in i ed o pa icipa e. The sample size was es ima ed o exceed he ecommended 10:1 a io o he numbe o subjec s o he numbe o es i ems [ 36 ], and i was hus es ablished ha a ound 100 pa icipan s would be needed a a minimum. In i a ions we e sen o 1600 po en ial pa icipan s ia email, wi h ollow-up emails sen h ee imes in h ee weeks o achie e he g ea es possible esponse a io (RR). A o al o 407 pa icipan s esponded o he s udy su ey wi h no missing da a and we e he e o e included in he analyses. The sociodemog aphic cha ac e is ics o he sample a e summa ized in Table 1. The a e age age o he sample was 41.09 yea s (SD = 10.09). The majo i y o he sample we e emale (84.5%), had a pa ne (70.3%), had child en (60.7%), and we e p o essionals who wo ked wi h a sala y (61.2%). Physicians accoun ed o 17.7% o he sample, nu ses accoun ed o 25.1%, and communi y heal h wo ke s accoun ed o 57.2% o he sample. The a e age leng h o se ice was 17.19 yea s (SD = 9.81), wi h a mean o 5.47 yea s (SD = 5.53) a he cu en wo kplace. Mos pa icipan s had pe manen (90.4%) and ull- ime (89.9%) con ac s. None heless, 84.0% epo ed ha ing economic di icul ies o some ex en . Pa icipan s wo ked o a mean o 39.25 h pe week (SD = 26.81). Those who ha e had sick lea e absences du ing he p e ious yea (35.6%) showed an a e age o 19.0 sick lea e days (SD = 51.83). The pa icipan s ga e hei p io online in o med consen , a es ing o hei willingness o pa icipa e. The e hics commi ee o he Fede al Uni e si y o São Paulo (UNIFESP; 26-10-2016; CAAE 30374114.1.0000.5505) app o ed his s udy. 2.2. Measu emen s Sociodemog aphic in o ma ion was collec ed ega ding age; sex (male, emale); ela- ionships (wi h pa ne /ma ied, wi h no pa ne ); he numbe o child en; p o essional In . J. En i on. Res. Public Heal h 2023,20, 225 4 o 13 ca ego y ( olun ee , p o essional wi h a sala y); job posi ion (physician, nu se, communi y heal h wo ke ); hou s wo ked pe week; leng h o se ice in yea s; yea s a he same job; con ac pe iod ( empo a y, pe manen ); con ac ype ( ull- ime, pa - ime); economic di icul ies (ne e o always); and sick lea e in he pas yea (including days o sick lea e). Table 1. Sociodemog aphic cha ac e is ics o s udy pa icipan s. Va iables Age (yea s), M(SD) 41.09 (10.09) Sex ( emale), n(%) 344 (84.5) Rela ionship (pa ne ship/ma ied), n(%) 286 (70.3) Numbe o child en (none), n(%) 160 (39.3) Ca ego y, n(%) Volun ee 158 (38.8) P o essional wi h a sala y 249 (61.2) Job posi ion, n(%) Physician 72 (17.7) Nu se 102 (25.1) CHW 233 (57.2) Hou s wo ked pe week, M(SD) 39.25 (26.81) Leng h o se ice (yea s), M(SD) 17.19 (9.81) Yea s a he same job, M(SD) 5.47 (5.53) Con ac pe iod, n(%) Tempo a y 39 (9.6) Pe manen 368 (90.4) Con ac ype, n(%) Full- ime 366 (89.9) Pa - ime 41 (10.1) Economic di icul ies, n(%) Ne e 65 (16.0) Some imes 153 (37.6) Almos always 112 (27.5) Always 77 (18.9) Sick lea e in he pas yea (yes), n(%) 145 (35.6) No e: CHW: communi y heal h wo ke s. The AAQ-II measu es EA as he inabili y o ac in he p esen momen , based on alue- di ec ed ac ions, when expe iencing dis essing psychological e en s. EA is, he e o e, an example o psychological in lexibili y [ 4 ]. The AAQ-II consis s o se en i ems (e.g., “Emo ions cause p oblems in my li e”), and he i ems a e esponded o on a Like - ype scale (1 = ‘ne e ’ o 7 = ‘always’). Highe sco es indica e g ea e le els o EA. The Po uguese ansla ion o he ques ionnai e, o iginally p oposed o be used in B azil [ 15 ], was used and e alua ed in he p esen s udy. The Sel -Compassion Scale (SCS) [ 37 ] is a ques ionnai e ha measu es ace s o sel - compassion: ‘sel -kindness’, ‘common humani y’, ‘mind ulness’, ‘sel -judgemen ’, ‘iso- la ion’, and ‘o e -iden i ica ion.’ The las h ee ace s comp ise a sub-g oup o nega i e ac o s called sel -c i icism [ 21 ] and include 13 i ems ha assess how esponden s pe cei e hei ac ions owa ds hemsel es in di icul si ua ions. These i ems a e esponded o on a Like - ype scale (1 = ‘almos ne e ’ o 5 = ‘almos always’). Highe sco es in he ace s o sel -judgmen (e.g., “I y o see my ailu es as pa o he human condi ion”), isola ion (e.g., “When I’m eeling down, I end o eel like mos o he people a e happie han I am”), and o e -iden i ica ion (e.g., “when I’m eeling down, I end o obsess and ixa e on e e y hing ha is going w ong”) indica e g ea e sel -c i icism. I has been ob- se ed ha he sel -c i icism i ems ha e be e psychome ic p ope ies han he comple e SCS ques ionnai e [ 21 ]. The B azilian- alida ed e sion o he nega i e subscales o he In . J. En i on. Res. Public Heal h 2023,20, 225 5 o 13 SCS was used [ 21 ]. The in e nal consis ency alues in he p esen s udy we e as ollows: sel -judgemen (ω= 0.83), isola ion (ω= 0.80), and o e -iden i ica ion (ω= 0.78). The Fi e Face Mind ulness Ques ionnai e (FFMQ) [ 38 ] is a 39-i em ques ionnai e ha measu es mind ulness skills. Each i em is sco ed on a Like - ype scale (1 = ‘ne e ’ o 5 = ‘almos alwa ys’). These 39 i ems a e di ided in o i e mind ulness ace s: ‘obse ing’ (i.e., no icing o a ending o in e nal and ex e nal expe iences such as sensa ions, hough s, o emo ions); ‘desc ibing’ (i.e., labeling in e nal expe iences wi h wo ds); ‘ac ing wi h awa eness’ (i.e., ocusing on one’s ac i i ies a a gi en momen as opposed o beha ing me- chanically); ‘non-judging’ o inne expe ience (i.e., aking a non-e alua i e s ance owa ds hough s and eelings); and ‘non- eac i i y’ o inne expe ience (i.e., allowing hough s and eelings o come and go wi hou ge ing caugh up in hem o being ca ied away by hem). The B azilian- alida ed e sion o he FFMQ was used [ 39 ]. The FFMQ dimensions showed good in e nal consis ency in he p esen s udy, wi h ω alues be ween 0.70 (non- eac i i y) and 0.87 (ac ing wi h awa eness). The Hospi al Anxie y and Dep ession Scale (HADS) [ 40 ] is a 14-i em ques ionnai e used o de e mine he le els o a ec i e symp oma ology and p obable cases o anxie y and dep ession. I consis s o wo subscales (7 i ems each): HADS-Anxie y (e.g., “I eel ense o wound up”) and HADS-Dep ession (e.g., “I eel as i I am slowed down”). Each i em can be sco ed om 0 o 3. The ollowing cu -o poin s o each subscale ha e been p oposed: ≤ 7 (no anxie y/dep ession); 8–10 (mild anxie y/dep ession); 11–14 (mode a e anxie y/dep ession); and 15–21 (se e e anxie y/dep ession). Bo h he HADS-Anxie y and HADS-Dep ession subscales ha e demons a ed sensi i i y and speci ici y alues o app oxima ely 0.80 [ 41 – 43 ]. The Po uguese e sion o he HADS was used [ 41 ]. The in e nal consis ency in he p esen s udy was anxie y ( ω = 0.83) and dep ession ( ω = 0.82). 2.3. Da a Analyses Sociodemog aphic da a we e desc ibed using means (SDs), o equencies (pe cen - ages), acco ding o he na u e and dis ibu ion o each a iable. We desc ibed i em cha ac e is ics by calcula ing means (SDs), skewness, ku osis, i em- es co ela ions, and polycho ic co ela ions. We checked whe he he heo e ically p edic ed unidimensional s uc u e o he AAQ-II holds o B azilian PC p o ide s by using pa allel analysis (PA) and con i ma o y ac o analysis (CFA). Pa allel analysis (PA) was used o iden i y whe he he numbe o ac o s o e ain co esponded o he o iginal one- ac o solu ion. This was ca ied ou by op imal implemen a ion based on minimum ank ac o analysis, gene a ing 500 andom co ela ion ma ices [ 44 ]. Wi h his p ocedu e, a ac o is signi ican i he associa ed eigen alue is la ge han ha co esponding o a gi en pe cen ile (95 h o he dis ibu ion o eigen alues de i ed om he andom da ase ). A e es ing he numbe o ac o s o e ain, we de eloped a CFA and calcula ed s anda dized ac o ial weigh s and he pe cen age o explained a iance in each i em by means o communali y alues. The iabili y o he CFA model was es ed using he compa a i e i index (CFI), he Tucke –Lewis index (TLI), he oo -mean-squa e e o o app oxima ion (RMSEA), and he weigh ed oo -mean-squa e esidual (SRMR). The CFI compa es he i o a a ge model o he i o a null model (wi h alues ≥ 0.95 o good and ≥ 0.90 o accep able). The TLI is mo e sensi i e o sample size (wi h alues ≥ 0.95 o good and ≥ 0.90 o accep able). The RMSEA is a measu emen o he e o o app oxima ion o he popula ion (wi h alues ≤ 0.06 o good and ≤ 0.10 o accep able). Las ly, he SRMR is he s anda dized di e ence be ween he obse ed and he p edic ed co a iance (wi h alues ≤0.06 o good and ≤0.10 o accep able) [45,46]. The in e nal consis ency o he scale was de e mined by calcula ing McDonald’s omega ( ω ) composi e eliabili y, wi h coe icien s ≥ 0.70 indica ing adequa e in e nal consis ency alues [ 47 ]. McDonald’s ω has he ad an age o conside ing he s eng h o associa ion be ween i ems and cons uc s and i em-speci ic measu emen e o s, p o iding a mo e eal- is ic es ima e o ue eliabili y han C onbach’s alpha [ 48 , 49 ]. Mean in e -i em polycho ic co ela ions and mean i em- es co ela ions we e also calcula ed. In . J. En i on. Res. Public Heal h 2023,20, 225 6 o 13 The con e gen /di e gen alidi y o EA, sel -c i icism, and mind ulness skills was calcula ed using Pea son’s co ela ion coe icien . Pa ial co ela ion coe icien s we e cal- cula ed o ha e a co ela ion es ima e a e con olling o he in luence o he o he ac o s (i.e., subscales o sel -c i icism and mind ulness). We also e alua ed he ex en o which sel -c i icism and mind ulness explained EA by cons uc ing mul iple linea eg ession models. The nega i e subscales o he SCS and FFMQ subscales we e conside ed indepen- den a iables. A he same ime, he la en alue o he AAQ-II, calcula ed acco ding o he Bayes expec ed a pos e io i me hod (EAP) [ 50 ], was conside ed he dependen a iable. The indi idual con ibu ion o he independen a iables in he mul i a ia e model was es ima ed by s anda dized slope (be a) coe icien s. The Wald es was used o e alua e i s signi icance. The signi icance o he model’s explana o y powe was examined by analy- sis o a iance (ANOVA). The mul iple co ela ion coe icien and he adjus ed mul iple de e mina ion coe icien we e also es ima ed. Tole ance alues we e calcula ed o ule ou possible collinea i y p oblems; he Kolmogo o –Smi no es was used o de e mine i esiduals we e no mally dis ibu ed; and Du bin–Wa son (DW) alues we e assessed o ule ou au oco ela ion p oblems in he e o e ms (c i e ion: DW ≈2.00) [51]. The c i e ion alidi y o EA on HADS-A and HADS-D was assessed by plo ing ecei - ing ope a ing cha ac e is ics (ROC) cu es compa ing he AAQ-II wi h he HADS anxie y and dep ession subscales. The a ea unde he cu e (AUC) was calcula ed o ep esen he capaci y o he AAQ-II o disc imina e be ween cases and non-cases acco ding o he s a es o anxie y and dep ession, applying he cu -o c i e ia a o emen ioned. Sensi i i y and speci ici y alues we e used as case iden i ica ion and non-case ecogni ion measu es. Posi i e and nega i e p edic i e alues we e also es ima ed o asce ain he capaci y o he AAQ-II o de ec ue and alse cases. O e all misclassi ica ion a es we e calcula ed. The Youden Index was also calcula ed, which is una ec ed by p e alence a es and ep esen s he di e ence be ween he p opo ions o ue cases and alse cases iden i ied, wi h a highe alue indica ing a mo e app op ia e cu -o poin . The le el o signi icance adop ed in he es s was p< 0.05. Da a analyses we e ca ied ou using he SPSS 28.0 (SPSS Inc., Chicago, IL, USA) and he Mplus 8.8 (Mú hen & Mú hen, Los Angeles, CA, USA) s a is ical so wa e packages. 3. Resul s 3.1. S uc u al Validi y o he B azilian AAQ-II Table 2shows he desc ip i e and psychome ic cha ac e is ics o he AAQ-II i ems. PA iden i ied a one- ac o solu ion, explaining 81.0% o he a iance. The CFA model o he one- ac o solu ion p esen ed app op ia e goodness o i indices (CFI = 0.97; TLI = 0.95 ; RMSEA = 0.08 (90% CI = 0.05–0.010); SRMR = 0.03). The s anda dized weigh s o he i ems anged om 0.74 o 0.88. The communali y alues o he i ems we e ≥ 0.55. As he heo e ical mean o each i em conside ing he Like - ype scale used ( anging om 1 o 7) is ou , empi ical means we e sligh ly below he heo e ical mean. Table 2. Desc ip i e and psychome ic cha ac e is ics o he AAQ-II i ems (n= 407). I ems Mean (SD) Skewness Ku osis I em-Res λh2 I em 1 3.21 (1.75) 0.53 −0.62 0.79 0.83 0.70 I em 2 3.11 (1.75) 0.56 −0.58 0.82 0.85 0.73 I em 3 3.59 (1.81) 0.27 −0.87 0.77 0.81 0.66 I em 4 3.01 (1.84) 0.65 −0.63 0.83 0.88 0.77 I em 5 3.55 (1.70) 0.27 −0.63 0.73 0.75 0.56 I em 6 3.40 (1.79) 0.33 −0.87 0.72 0.74 0.55 I em 7 3.57 (1.72) 0.21 −0.83 0.75 0.77 0.59 No e: λ= CFA s anda dized eg ession weigh s. h2= communali y alues. In . J. En i on. Res. Public Heal h 2023,20, 225 7 o 13 3.2. In e nal Consis ency o he B azilian AAQ-II The McDonald’s omega composi e eliabili y index showed a alue o ω = 0.93. On he o he hand, he mean o he i em- es alues o he o al sample was 0.77 ( ange: 0.72 o 0.83), and he mean in e -i em polycho ic co ela ion was 0.65. In conjunc ion, all his in o ma ion sugges ed app op ia e le els o in e nal consis ency. 3.3. Con e gence/Di e gence and Explana o y Powe o Sel -C i icism and Mind ulness Table 3shows desc ip i e and Pea son co ela ions be ween he AAQ-II and sel - c i icism and mind ulness skills. Co ela ions indica ed ha he AAQ-II was s ongly and posi i ely associa ed wi h all he sel -c i icism sub-dimensions (e.g., sel -judgemen , isola ion, and o e -iden i ica ion). In addi ion, he AAQ-II was also s ongly and nega i ely ela ed o ac ing wi h awa eness and non-judging o he inne expe ience subscales o mind ulness. We also obse ed small- o-mode a e nega i e co ela ions be ween he AAQ- II and he mind ulness ace s o non- eac i i y o inne expe ience and desc ibing. The AAQ-II showed no signi ican ela ionships wi h he obse ing ace . Table 3. Desc ip i e and co ela ions be ween he AAQ-II and sel -c i icism/mind ulness. Scales Mean (SD) AAQ-II ( ) AAQ-II ( ange: 7 o 49; heo e ical a e age: 28) 23.43 (10.34) Sel -judgemen ( ange: 5 o 25; heo e ical a e age: 15) 16.10 (4.14) 0.62 * Isola ion ( ange: 4 o 20; heo e ical a e age: 12) 11.81 (3.77) 0.66 * O e -iden i ica ion ( ange: 4 o 20; heo e ical a e age: 12) 12.51 (3.50) 0.69 * Obse ing ( ange: 5 o 40; heo e ical a e age: 24) 24.28 (7.41) −0.07 Desc ibing ( ange: 5 o 40; heo e ical a e age: 24) 26.98 (6.60) −0.27 * Ac ing awa e ( ange: 5 o 40; heo e ical a e age: 24) 21.73 (6.89) −0.47 * Non-judging ( ange: 5 o 40; heo e ical a e age: 24) 17.57 (7.10) −0.52 * Non- eac i i y ( ange: 5 o 35; heo e ical a e age: 21) 18.99 (4.98) −0.18 * No e: = Pea son’s co ela ions. * p< 0.001. The explana o y powe o he mul iple eg ession model was e y high (see Table 4), explaining 59% o he AAQ-II a iance. The obse ing and desc ibing ace s o he FFMQ we e he only subscales ha did no signi ican ly explain he AAQ-II a iance in he mul i- a iable model. The isola ion ace o sel -c i icism was he ac o ha mos ly explained AAQ-II a iance, ollowed by he non-judging o he inne expe ience ace o he FFMQ, he o e -iden i ica ion sel -c i icism ace , he sel -judgmen sel -c i icism ace , he ac ing wi h awa eness subscale o he FFMQ, and he non- eac i i y ace o he FFMQ (demon- s a ing nega i e ela ionships wi h he FFMQ). The ole ance alues anged om 0.27 o 0.68, which sugges s an accep able deg ee o o e lap among he sel -c i icism and mind ul- ness ace s. The esiduals o p edic ed alues showed a no mal dis ibu ion (p= 0.205), and he Du bin–Wa son alue was 2.05; hus, model assump ions we e me , and he mul iple linea eg ession analysis esul s could be in e p e ed wi h con idence. 3.4. C i e ion Validi y o he AAQ-II on Anxie y and Dep essi e Symp oms Pea son co ela ions indica ed ha he AAQ-II was s ongly and posi i ely associa ed wi h anxie y ( = 0.56; p< 0.001) and dep ession ( = 0.55; p< 0.001) symp oms. As de ailed in Table 5, he AAQ-II showed app op ia e alues o p edic abili y when explaining di e en le els o anxie y and dep essi e symp oms. Howe e , he sensi i i y-speci ici y a io was op imized when speci ically conside ing se e e s a es o anxie y o dep ession, meaning ha he AAQ-II be e p edic ed mo e se e e symp oms. In . J. En i on. Res. Public Heal h 2023,20, 225 8 o 13 Table 4. Explana o y powe o sel -compassion and mind ulness ace s on AAQ-II. Mul i a iable Model Ry.123 Adj-R2y.123 DW pa Independen a iables 0.77 0.59 *** 2.05 0.370 T Ry3.12 Be a pb Sel -judgemen 0.40 0.15 0.15 0.004 Isola ion 0.44 0.31 0.31 <0.001 O e -iden i ica ion 0.27 0.14 0.17 0.007 Obse ing 0.55 <0.01 <0.01 0.983 Desc ibing 0.60 −0.06 −0.05 0.220 Ac ing awa e 0.68 −0.17 −0.14 <0.001 Non-judging 0.61 −0.22 −0.19 <0.001 Non- eac i i y 0.62 −0.13 −0.11 0.008 No e: R y.123 = mul iple co ela ion coe icien . Adj-R 2y.123 = adjus ed mul iple de e mina ion coe icien . *** = p< 0.001 (p- alue associa ed wi h eg ession). DW = Du bin–Wa son. p a = Kolmogo o -Smi no no - mali y con as on esiduals. T = ole ance. R y3.12 = pa ial co ela ion coe icien . Be a = s anda dized slope. pb=p- alue o Wald es on s anda dized slopes. Table 5. C i e ion alidi y coe icien s o AAQ-II on HADS-anxie y and HADS-dep ession. Anxie y Mild/Mode a e/Se e e (AAQ-II > 20) Mode a e/Se e e (AAQ-II > 24) Se e e (AAQ-II > 27) Index 95%CI Index 95%CI Index 95%CI AUC 0.78 0.73–0.82 0.76 0.71–0.81 0.85 0.80–0.90 SEN 0.72 0.67–0.78 0.70 0.62–0.77 0.78 0.64–0.92 SPE 0.69 0.61–0.76 0.71 0.66–0.75 0.72 0.68–0.77 PPV 0.78 0.72–0.83 0.60 0.52–0.67 0.24 0.16–0.32 NPV 0.62 0.54–0.69 0.79 0.74–0.85 0.97 0.94–0.99 OMR 0.29 0.25–0.44 0.30 0.25–0.35 0.27 0.23–0.31 YIN 0.41 0.32–0.51 0.40 0.31–0.50 0.50 0.37–0.64 Dep ession mild/mode a e/se e e (AAQ-II > 23) mode a e/se e e (AAQ-II > 26) se e e (AAQ-II > 30) Index 95%CI Index 95%CI Index 95%CI AUC 0.78 0.73–0.82 0.76 0.70–0.82 0.87 0.80–0.94 SEN 0.74 0.67–0.81 0.70 0.60–0.81 0.84 0.68–1.00 SPE 0.71 0.65–0.77 0.70 0.65–0.75 0.82 0.78–0.86 PPV 0.65 0.58–0.72 0.40 0.32–0.48 0.23 0.14–0.32 NPV 0.79 0.74–0.85 0.90 0.86–0.94 0.99 0.97–1.00 OMR 0.28 0.23–0.32 0.30 0.25–0.34 0.18 0.14–0.22 YIN 0.45 0.36–0.54 0.41 0.30–0.59 0.66 0.51–0.81 No e: “mild/mode a e/se e e” = no (anxie y o dep ession) s. mild/mode a e/se e e. “mode a e/se e e” = n o (anxie y o dep ession)/mild s. mode a e/se e e. “se e e” = no (anxie y o dep ession)/mild/mode a e s. se e e. Cu -o s o he HADS a e speci ied in he measu emen s sec ion. AUC = a ea unde he cu e. SEN = sensi i i y. SPE = speci ici y. PPV = posi i e p edic i e alue. NPV = nega i e p edic i e alue. OMR = o e all misclassi ica ion a e. YIN = Youden index. 4. Discussion The main aim o his s udy was o assess he psychome ic p ope ies o he AAQ-II among B azilian PC p o ide s. Ou indings sugges ha he AAQ-II p esen s accep able s uc u al alidi y and in e nal consis ency. The analyses yielded a one- ac o solu ion, which is in line wi h he o iginal heo e ical p oposal [ 4 ] and subsequen adap a ions [52–56] . This solu ion explained mo e han 80% o he a iance wi h app op ia e goodness o i indices. The in e nal consis ency o he AAQ-II in e ms o McDonalds’ omega was se a 0.93, which is e y simila o he C onbach’s alpha alue epo ed in a p e ious alida ion s udy using B azilian unde g adua e s uden s [ 9 ]. I is also aligned wi h o he alida ion s udies om di e en coun ies and popula ions [ 9 – 13 , 52 , 54 – 57 ]. The e o e, he B azilian AAQ-II adap a ion seems o be a s uc u ally alid and in e nally consis en ins umen o measu e EA in B azilian PC p o ide s. In . J. En i on. Res. Public Heal h 2023,20, 225 9 o 13 As a seconda y objec i e, he p esen s udy aimed o assess he con e gence/di e gence o he AAQ-II wi h measu es o sel -c i icism and mind ulness skills, as well as he capac- i y o sel -c i icism and mind ulness o explain EA using he AAQ-II. We ha e obse ed ha bo h he absence o mind ulness skills and, la gely, he p esence o sel -c i icism was clea ly associa ed wi h EA. P e ious esea ch has sugges ed ha mind ulness skills, sel - c i icism (o i s sel -compassion coun e pa ), and EA may be playing a media ing ole in hi d-wa e cogni i e psychological he apies, including hose ha inco po a e medi a ion aining [ 31 ]. Nega i e co ela ions be ween mind ulness skills and EA ha e been widely epo ed [ 58 , 59 ], which is suppo ed by he heo e ical amewo k o mind ulness. This sugges s ha mind ulness skills enhance a en ional con ol, accep ance o one’s in e nal and ex e nal expe iences, and non- eac i i y o acu e s esso s [60]. Howe e , as has been obse ed in he p esen s udy, he mind ulness ace s o obse ing and desc ibing may be less associa ed wi h psychological symp oms [ 61 ] and pe haps mo e dependen on p e ious medi a ion expe ience [ 62 ]. On he o he hand, only a ew s udies ha e speci - ically iden i ied sel -c i icism (along wi h i s associa ed dimensions) as a cons uc ha migh be s ongly ela ed o EA. I is possible ha being excessi ely sel -c i ical du ing s ess ul li e ci cums ances makes i di icul o implemen emo ion- egula ion s a egies, such as sel -soo hing, heal hy eapp aisal, and emo ional accep ance [ 63 ]. Pas wo k has suppo ed a ela ionship be ween sel -c i ical pe ec ionism and i s p edic i e ole in in- c easing EA [ 64 ]. The isola ion ac o om he sel -c i icism cons uc was mo e s ongly associa ed wi h EA, which can be linked o p e ious indings ha ha e ound EA o be a signi ican media o be ween emo ion egula ion abili ies and loneliness [ 65 ]. In summa y, EA, mind ulness skills, and sel -c i icism seem o be h ee key in e ela ed psychological p ocesses called “ hi d wa e” CBTs, which place he ocus p ima ily on he ela ionship be ween he indi idual and hei in e nal expe ience (i.e., hough s, emo ions, and physical sensa ions) [66]. The hi d objec i e o he p esen s udy was o calcula e he c i e ion alidi y o he AAQ-II on anxie y and dep essi e symp oma ology. The esul s o he cu en pape p opose po en ial cu -o poin s o ha e an indi ec and, he e o e, less s igma izing measu e o men al heal h s a us. We obse ed EA using he AAQ-II o be highly associa ed wi h anxie y and dep essi e symp oms, especially in he con ex o mo e se e e symp oms. This esul has been obse ed in di e en clinical con ex s [ 58 ]. Longi udinal s udies con i m ha EA, as well as sel -c i icism, is a gene alized ulne abili y ac o ha con e s ansdiagnos ic isk [ 67 ]. Fo example, exposu e o auma is an ad e se li e e en closely linked wi h EA, which may inc ease he likelihood o agg a a ing symp oms o ecu ence in he con ex o men al diso de s [ 68 ]. EA is desc ibed as a “phenomenon ha occu s when a pe son is unwilling o emain in con ac wi h dis essing expe iences (e.g., bodily sensa ions, emo ions, hough s, memo ies, beha io al p edisposi ions) and akes s eps o al e he o m o equency o hese e en s and he con ex s ha a e associa ed wi h hem” [ 69 ]. Indi iduals who end o a oid uncom o able o unwan ed in e nal expe iences a e mo e ulne able o s ess because an a oidan esponse pa e n makes i di icul o implemen adap i e beha io s [ 69 ]. In line wi h ou esul s, EA has been ound o be a signi ican p edic o o s ess, anxie y, and dep ession [ 70 , 71 ]. As men ioned abo e, PC p o ide s show an inc eased isk o job- ela ed mood-diso de psychological dis ess [ 16 ], and e idence sugges s ha B azilian PC wo ke s a e likely o de elop anxie y o dep ession [ 17 ]. Fu he unde s anding o how PC wo ke s espond o hei in e nal expe iences (i.e., hough s, emo ions, u ges, sensa ions, memo ies, e c.) may p o ide impo an insigh s in o he ele ance o applying hi d-wa e app oaches (e.g., Mind ulness-Based P og ams, Compassion-Based P og ams, o Accep ance and Commi men The apy) in his con ex . In gene al, ou indings suppo he applica ion o p og ams based on inc easing mind ulness skills, educing sel -c i icism, and enhancing psychological lexibili y (by means o educing EA) o imp o e anxie y and dep ession in B azilian PC p o ide s [72]. The indings o his s udy should be in e p e ed in ligh o he limi a ions. Fi s , he ini ial s udy ha used a Po uguese e sion o he AAQ-II in a sample o B azilian