This Is My Baby Interview: An Adaptation to the Spanish Language and Culture

  Citation: Pinero-Pinto, E.; Benítez-Lugo, M.-L.; Chillón-Martínez, R.; Escobio-Prieto, I.; Chamorro-Moriana, G.; Jiménez-Rejano, J.-J. This Is My Baby Interview: An Adaptation to the Spanish Language and Culture. Children 2022,9, 235. https:// doi.org/10.3390/children9020235 Academic Editor: Hermano Alexandre Lima Rocha Received: 3 January 2022 Accepted: 9 February 2022 Published: 10 February 2022 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. Copyright: © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). children Article This Is My Baby Interview: An Adaptation to the Spanish Language and Culture Elena Pinero-Pinto , María-Luisa Benítez-Lugo * , Raquel Chillón-Martínez, Isabel Escobio-Prieto , Gema Chamorro-Moriana and José-Jesús Jiménez-Rejano Department of Physiotherapy, University of Seville, 41009 Seville, Spain; [email protected] (E.P.-P.); [email protected] (R.C.-M.); [email protected] (I.E.-P.); [email protected] (G.C.-M.); [email protected] (J.-J.J.-R.) *Correspondence: [email protected]; Tel.: +34-95-4486501 Abstract: Evaluating the emotional state of parents is important for determining the intervention in the context of a family with a baby with Down syndrome. “This is my baby” is an interview that measures the acceptance, commitment and awareness of influence of parents towards their baby. The Spanish adaptation of this instrument helps to better understand the emotional state of parents of children with developmental disorders. A cross-cultural adaptation and reliability analysis was carried out. The results suggest that the Spanish version of the This Is My Baby interview is a reliable instrument to measure the levels of acceptance, commitment and awareness of influence of parents of an infant with Down syndrome. Keywords: interview; parents; Down syndrome; reliability 1. Introduction The family directly influences early childhood development in children with Down syndrome. Parents are better positioned to facilitate their children’s development, as they can maximize opportunities in everyday situations; therefore, early intervention services are integrated in the home and mediated by both parents and caregivers [1,2]. Different studies on Down syndrome performed in natural environments [ 1 , 3 ] demonstrate the importance of the interactions between parents and their infants with Down syndrome. Some authors [ 1 , 4 , 5 ] considered that if mother–baby interaction is promoted during early intervention by professionals, it is possible to improve the cognitive and motor development quotient of babies with Down syndrome. Parents who have followed the family-centered model during the intervention say that, by spending more time on the maturational development of their children with Down syndrome, it has been easier to accept their baby’s disability situation, as they have committed to the intervention and have realized that they can influence their baby [ 6 ]. The results of the study conducted by Mas et al. [ 7 ] indicate that the use of family-centered practices can have positive effects on the emotional well-being of parents, not only on their relationship with the baby. For all of the above, it seems that the intervention carried out from the family, and the promotion of the parent–child relationship, e.g., through infant massage, can help to improve the emotional state of the parents and the development of the baby [6,8–11]. Acceptance and commitment therapies can be included in family-focused therapies with the aim of improving the psychological state of parents, e.g., to increase their ability to modify their behavior with full awareness of their experience and context of the present moment. Therefore, the importance of rewarding values or behavior patterns, present moment awareness or mindfulness, and experiential acceptance or ongoing, open and responsive contact with the child in an emotionally challenging situation are emphasized [ 2 ]. Numerous challenges and difficulties present themselves when rearing children with developmental disorders [ 12 ]. It has been shown that mothers of babies with Down syndrome Children 2022,9, 235. https://doi.org/10.3390/children9020235 https://www.mdpi.com/journal/children Children 2022,9, 235 2 of 15 who are more dependent and need more care experience higher levels of emotional and mental health distress [ 13 ]. In general, babies need great care, thus the addition of a disability has a negative impact on maternal mental health. The readiness to receive information about their child affects the phases that parents go through, from diagnosis to acceptance of the disorder. Parental commitment during pregnancy and in the immediate months after childbirth is affected by many aspects, including happiness and emotional well-being. The greater the happiness of the parents and the better their emotional state, the greater their commitment to their children. A situation of emotional stress can affect the vulnerability of parents and decrease their commitment [ 14 ], as occurs in families with babies with Down syndrome [ 8 ]. Thus, it is important to take into account the evaluation of the emotional situation of the parents before intervening with a family in family-centered models [ 12 ], as the variables and feelings mentioned in the different phases influence the origin and persistence of family stress. Thus, Ruiz-González et al. [ 15 ] considered this when planning the intervention with the family, a fundamental aspect of which is to involve them actively. As stated by Oppenheim et al. [ 16 ], in cases of diagnosis of pathology or serious disorder, the study of the parents’ state of mind should include not only introspection but also acceptance. In this sense, evaluations of the mental health of parents [ 7 , 17 ] and the impact of the arrival of a child with Down syndrome on the family [ 6 ] have been developed, although there are no evaluations of how parents accept the new situation and commit to the baby. Although parents of children with Down syndrome directly influence the development of the latter [ 1 , 4 ], it is known that the emotional state of the parents is a dynamic process that changes over time [ 12 , 14 ]. The awareness of the influence of parents of typically developing children is high in relation to their role in their children’s development [ 18 ]; however, there are no studies that describe the awareness of the influence of parents with children with Down syndrome. When analyzing the emotional state of parents with babies with Down syndrome, variables such as depression [ 10 , 19 ], anxiety [20,21] and resilience [ 3 , 12 ] are taken into account, whereas other variables are disregarded, such as acceptance, commitment and awareness of influence. The TIMB interview was created by Bates and Dozier [ 22 ] to measure the acceptance, commitment and awareness of parental influence. It is a semi-structured interview with an approximate duration of 5–15 min. There are three versions, designed for foster, adoptive and biological parents, each with eight questions. There is only one question that differs from the rest in all three versions. Although this interview was created for foster and adoptive families, or parents with children who have a history of foster care placement, families who receive a diagnosis of a child with a disorder often reject the baby and do not accept it as their own until they are committed to and accept the situation of disability [ 23 ]. Therefore, this instrument can be used to verify whether there is a psychological conflict between the parents and the baby, in relation to acceptance, commitment and awareness of influence, which can influence their development. However, there is no tool in the Spanish language to assess the acceptance, commitment and awareness of parental influence. These variables should be studied in families with babies with Down syndrome, as it has been shown that these variables have been described in the available scientific literature as determining aspects in the development of babies with Down syndrome. Therefore, it is necessary to adapt a specific scale to the Spanish language and culture, such as the “This Is My Baby” (TIMB) interview. 2. Materials and Methods 2.1. Design The present study consists in the transcultural adaptation of the TIMB interview and the determination of its reliability, sensitivity to change and internal consistency. This work followed the tenets of the Declaration of Helsinki. The parents who answered the interview were informed in written and oral form about the study characteristics, benefits and risks. The participants gave their written informed consent after the nature and possible Children 2022,9, 235 3 of 15 consequences of the study were explained to them. The ethics committee of the University of Seville approved this research. 2.2. Population and Sample 2.2.1. Sample, Sampling, and Scope of Study A total of 32 families of babies with Down syndrome participated in this multicenter study conducted in the Autonomous Community of Andalusia. The participating families were members/users of associations for people with Down syndrome and other disabilities and early childhood intervention centers. The babies of the participating families had an average age of 155.72 days (standard deviation (SD) = 39.46), with a minimum of 117 days and a maximum of 235 days. Of the 32 babies, 21 (65.6%) were boys and 11 (34.4%) were girls. In four (12.5%) of the cases, the interviewees were the fathers and in 28 cases (87.5%) they were the mothers. In addition, 17 (53.1%) of the babies had no siblings, whereas the other 15 (46.9%) had siblings. 2.2.2. Selection Criteria Inclusion criteria: families of babies with Down syndrome aged between four and eight months who received early childhood intervention (data from the babies were collected in parallel). Exclusion criteria: families with adopted or foster babies with Down syndrome, parents who suffer from psychiatric disorders and parents whose babies with Down syndrome suffer from associated disorders or serious illnesses (babies with Down syndrome with untreated pathologies of the heart or kidneys or digestive diseases, with another developmental disorder associated, or premature babies with Down syndrome). A convenience non-probabilistic sampling was performed, initially contacting 43 families, of which eight did not participate, as the babies had already reached the age of eight months at the time of the interview. Three other families were subsequently excluded: two for not completing the intervention within the stipulated time, and the third one because the interview could not be conducted at the end of the intervention period. 2.3. Coding and Measurement Procedure When performing any version of the TIMB interview, the tone of the interview should be conversational and should not sound like a reading, thus the questions should be memorized. Parents answer with little or no help from the interviewer, although, if the answers are short or difficult to understand, the interviewer should assist them. The use of a tape recorder is necessary for the subsequent transcribing of the answers. The coding system consists of three indices (acceptance, commitment and awareness of influence), which reflect what the mother or father thinks about their infant and the relationship they have with him/her. The recording of the interview and its transcription allow the interviewer to classify the three indices and to codify them on a five-point Likert scale. Point and half point scores (e.g., 2.5) are accepted. The specific results are based on the weight of the positive and negative indicators of the three indices. These indicators can be the words used by the parent to describe the baby, the tone of voice used, the degree of congruence in their responses, the independence they transmit about their baby, the evidence of how important the baby is to the parent, and the experiences and examples given when endorsing their answers. Pausing to think about the answers and sharing bad experiences to back their answers tend to be negative indicators in the three indices. Coding Responses into Indices The parents were asked to develop short responses. The score is given by the content (words used), the tone of the conversation, the time to give the answer and the congruence in the answers (see Table 1with the rubric used to code). Children 2022,9, 235 4 of 15 Table 1. Rubric to code the parents’ responses on the Likert scale for the indices of acceptance, commitment and awareness of influence. 12345 Acceptance Words and content Rejection or disgust when talking about the child Negative maternal feelings No positive or negative words, or mixed words Relationship is positive Describes relationship as very positive Tone of conversation Very hostile tone Hostile tone Medium Positive tone Very positive tone Time to give the answer Very large Large Medium Quick answer Very quick answer Commitment Words and content Talks about the child as if he/she were not his/hers Little feeling of belonging Mixed words Feelings of belonging Obvious feelings of belonging Tone of conversation No efforts to form an affective bond Little efforts to form an affective bond Mixed tone during interview Active efforts to form an affective bond Very active efforts to form an affective bond Time to give the answer Very large (too many pauses) Large Medium Quick answer Very quick answer Awareness of influence Words and content Does not show that he/she influences the baby Some sign about his/her influence Mixed content Promotes the child’s sense of being loved or feeling secure Promotes the development of age-appropriate psychological autonomy Tone of conversation Great hostile tone, speaking of the baby in the third person Hostile tone Mixed tone Loving tone Great loving tone, of affection Time to give the answer Very large (too many pauses) Large Medium Quick answer Very quick answer Examples of answers that code for “Acceptance”: “Pablo is a lovely child; I love watching him sleep [ . . . ] although sometimes I feel sorry when I look at him” (positive tone at first, but hostile tone at the end) (assigned score 3). “This girl is too good, you know, she does nothing, she is not awake much, she eats and sleeps, she is a bit boring. But I guess these kids are like that [ . . . ] as they are slower” (sad tone and long sentences, with silences) (assigned score 1). Parents with a high level of commitment showed evidence of a strong emotional investment in the child and the consideration of the child as their own [ 24 , 25 ], in relation to the sense of belonging within a family and the affective parent–child bond. Examples of answers that code for “Commitment”: “I don’t know what I would do without him, although he’s not what I expected” (affectionate tone, looking at the baby and smiling) (assigned score 4). “Well, yes, I miss him if I’m not with him, but, come on . . . not so much yet because he was only recently born and I haven’t had time to miss him” (pauses in his/her response, listlessness in tone) (assigned score 1). The key concept for rating awareness of influence is the degree to which the parent is predominantly focused on psychological, social or affective influences and goals as opposed to concrete influences or the achievement of physical goals [22]. Examples of answers that code for “Awareness of Influence”: Children 2022,9, 235 5 of 15 “I will try to give her what she needs [ . . . ], we will do what we can to help Marta and make her happy [ . . . ] even if it means a change of plans in the family” (positive tone, with hope and enthusiasm, quick responses) (assigned score 4). “Well, I don’t know how we can take care of a child like that, we are not prepared for that [ . . . ] I don’t know how to do this” (speaks in the third person of the baby, as if he/she were not present, hesitant) (assigned score 1) Below are the eight interview questions corresponding to the version for biological parents [22]: 1. I would like to begin by asking you to describe (child’s name). What is (his/her) personality like? 2. If (child’s name) ever had to leave your care, how much would you miss (him/her)? 3. How do you think your relationship with (child’s name) is affecting (him/her) right now? 4. How do you think your relationship with (child’s name) will affect (him/her) in the long-term? 5. What do you want for (child’s name) right now? 6. What do you want for (child’s name) in the future? 7. Is there anything about (child’s name) or your relationship that we have not touched on that you would like to tell me? 8. I would like to end by asking a few basic questions about your experience as a parent: a. How many biological and/or adopted children do you have? b. How many biological and/or adopted children are currently living in your home? Other studies have established acceptable levels of inter-rater reliability in the practical transcripts coded from the interviews. Twenty percent of the interviews in these previous studies were coded by both evaluators as a measure of reliability. The Spearman correlations for reliability between the evaluators (i.e., inter-rater) were 0.89 [ 26 ] and 0.90 [ 24 ]. Caregiver engagement scores ranged from 1 to 5 (M = 3.8 and standard deviation (SD) = 1.2) [ 26 ] and (M = 3.3, SD = 1.1) [24]. 2.4. Procedure of Transcultural Adaptation to Spanish The interview we aimed to adapt and validate is the one originally developed in English by Bates and Dozier [ 22 ] for biological parents. For the work of transcultural adaptation, the recommendations of Argimon et al. [ 27 ] were followed. The adaptation of an interview to another culture cannot be reduced to a mere literal translation but must follow a methodology that ensures the conceptual and semantic equivalence with the original and the understanding of the adapted version by the subjects. The most widely used method is translation–retranslation by bilingual people, followed by an analysis of the new version to detect discrepancies and to verify that it is understandable by a group of people. The TIMB interview was translated into Spanish, with the prior authorization of the author of the original version, and then it was evaluated according to the following specific sequence of analysis: 1. The phenomenon to be measured was found to exist in the Spanish culture. In this sense, the definitions of acceptance, commitment and awareness of influence in Spanish and English were verified in the scientific literature, proving that, regardless of the language, the concepts did not vary and apply to numerous contexts, especially in infant psychology, adoption and disability [14]. 2. The questionnaire was translated into Spanish and its conceptual equivalence was evaluated. The translation of the questionnaire was performed at two different time points, as the aim was for this translation to be rather conceptual than literal [ 27 ]. Two bilingual Spanish physiotherapists, who also knew the contents and purpose of the questionnaire, collaborated in this study, in order to prevent mistakes in the Children 2022,9, 235 6 of 15 translation. From these translations, a meeting was held with the translators to agree upon the first Spanish version of the questionnaire. Subsequently, several experts in acceptance, commitment and awareness of influence evaluated the conceptual equivalence of this version with the original in English. 3. The questionnaire was retranslated into English. Once the first translated version was obtained, it was sent separately to two native bilingual English translators who specialize in health science research papers and were unaware of the original questionnaire [ 27 ]. Subsequently, a meeting was held with the translators to verify that the retranslation did not differ conceptually from the original version and thereby validate the first translation into Spanish. 4. A pilot study was carried out. This translated interview, which was considered as a draft, was submitted to a pilot study of ten fathers and mothers with babies with Down syndrome with the same characteristics as those of the families of the final sample. The aim of this pilot study was to identify confusing words or questions and to make sure that the interview questions were perfectly understandable to the mothers and fathers. During the application of this pilot study, the researchers were present to solve any doubts that the parents could have about the questions. In addition, the participants were asked to indicate those words or phrases that were confusing and give their opinion. Thus, the participants found the questions easy to understand. This did not imply any change in the wording of the questions, as no difficulties were found in the whole process of translation and retranslation. Due to the simple language used by the author of the original version, it was easy for the participants to read the questions in the study pilot. Consequently, it can be affirmed that the lexical conditions and comprehension of the items of the interview are suitable for its application. 5. Application of the interview to 32 families with babies with Down syndrome using its final version. The pertinent statistical tests were carried out to assess the concordance of the different evaluations, the interpretation of the results, the ceiling and floor effect, and the internal consistency and sensitivity. A study was carried out with these parents, with the randomization of two groups using the sealed envelope system. Sixteen parents were assigned to a group that would receive massage therapy and the other sixteen were assigned to a control group that did not receive this intervention. This massage intervention consisted of five one-hour sessions, once per week, where the parents were taught the different infant massage maneuvers [ 4 ]. The allocation to the groups was done blindly and the interviewers were also blinded to the randomization of the groups. The evaluations and interviews were carried out by different people. The test–retest was performed with the 16 parents of the control group, who received no intervention. The scores assigned to the parents after the evaluations carried out by a second expert (expert 2) to measure the test– retest reliability were agreed upon with the families who answered; this allowed the former to check the score that was assigned to their answers, based on the tone of the conversation, the words used and the time to answer, among other aspects. 2.5. Data Collection for the Validation of TIMB Interview To collect the data, a researcher interviewed the parents who have agreed to participate and met the inclusion criteria. The same researcher who interviewed the parents transcribed the interviews and assigned them their index according to a Likert-type scale. Then, this researcher listened to them again, and then reassigned them a new value blindly in each scale, without taking into account the initial values, and with a time difference of one month between both evaluations. Subsequently, an expert in early care and attention to families listened to and read the transcripts of the interviews (also blindly) to give them the value that she considered at each scale. Finally, expert 2, who was familiar with the tool, interviewed, for the second time, the 16 families who did not receive any type of intervention, in order to measure the test–retest reliability of the instrument. Children 2022,9, 235 7 of 15 To understand how responses are converted into indexes, a section on specific results was included to show possible responses from parents and how they are converted into indexes, according to the coding manual of the original authors [22]. 2.6. Data Analysis The gathered data were analyzed using the IBM SPSS software package (SPSS Statistics 26.00, Chicago, IL, USA), Gpower 3.1.9.2 (HHU, Düsseldorf, Germany) [ 28 ] and Epidat 4.2 (Galicia Xunta, A Coruña, Spain) [ 29 ]. All statistical tests were performed considering a 95% confidence interval (p-value < 0.05). First, the reliability of the Spanish version of the TIMB interview was analyzed. A description of the following data was provided: (1) the data obtained by the researcher in the evaluation performed at the beginning of the intervention (1st researcher measurement), (2) the data obtained in a second evaluation conducted on the same recordings with a difference of one month (2nd researcher measurement), (3) the data obtained by the expert evaluator and (4) the data obtained by expert 2 in two measurements with 16 subjects (test-retest). The description of these data includes the mean, standard deviation, median, first and third quartile and range scores for the three scales (acceptance, commitment and awareness of influence). For the reliability study, the inter-rater reliability between the 1st researcher measurement and the 2nd researcher measurement was analyzed. Subsequently, we assessed the consistency of the results achieved in the 1st and 2nd researcher measurements with those of the expert evaluator. The test–retest reliability was also studied in 16 subjects, comparing the values of two measurements made by expert 2. We determined the value of the intra-class correlation coefficient (ICC) [ 30 , 31 ]. An alpha model was used with two-way and mixed effects with absolute agreement for the intra-rater reliability, testretest and two-way random effects with absolute agreement for inter-rater reliability [ 32 ]. To complement the ICC study, we obtained the standard error of measurement (SEM) and the minimum detectable change (MDC) [ 33 ]. In addition, the weighted Kappa coefficient was calculated employing the Cicchetti method. Then, the presence of ceiling and floor effects was determined. The internal consistency was evaluated by calculating the Cronbach Alpha coefficient. In each case, the value of said coefficient was verified if any of the three indices considered were eliminated (acceptance, commitment and awareness of influence). In addition, we calculated new variables, which we called “differences”, between each pair of evaluations, finding the average value of each of the difference variables and their confidence interval at 95%. In addition, the Bland and Altman graphs were performed [34]. Finally, we determined the responsiveness of the instrument, using data from a clinical trial in which 16 of the babies in our sample underwent treatment by infant massage, calculating the effect size (with the Gpower 3.1.9.2 program, HHU, Düsseldorf, Germany) of the differences found between the pre- and post-intervention values. 3. Results Table 2shows a description of the data obtained by the researcher in the 1st and 2nd measurements, those obtained by the expert evaluator in the test carried out on 32 families and those obtained in the retest carried out on 16 families by expert 2. Children 2022,9, 235 8 of 15 Table 2. Description of the data obtained in the evaluations carried out by the principal investigator (first and second measurements), those obtained by the expert evaluator and those obtained in the test and retest. Index Mean Standard Deviation Median 1st–3rd Quartile Range Floor Effect (% Value 1) Principal investigator—1st measurement n= 32 Acceptance 2.172 0.921 2.0 1.250–3.0 1.0–4.0 25 Commitment 2.453 0.836 2.0 2.0–3.0 1.0–4.0 9.4 Awareness of influence 2.688 0.849 3.0 2.0–3.0 1.0–4.50 3.1 Principal investigator–2nd measurement n= 32 Acceptance 2.203 1.007 2.0 1.0–3.0 1.0–4.0 28.1 Commitment 2.375 0.852 2.0 2.0–3.0 1.0–4.0 9,4 Awareness of influence 2.563 0.849 2.5 2.0–3.0 1.0–4.0 9.4 Expert test n= 32 Acceptance 2.188 1.045 2.0 1.0–3.0 1.0–4.50 28.1 Commitment 2.422 0.993 2.0 1.750–3.0 1.0–4.50 9.4 Awareness of influence 2.578 0.881 3.0 2.0–3.0 1.0–4.0 9.4 Expert test n= 16 Acceptance 2.188 1.047 2.0 1.250–2.750 1.0–4.50 25.0 Commitment 2.438 0.947 2.0 2.0–3.0 1.0–4.50 6.3 Awareness of influence 2.531 0.921 3.0 1.750–3.0 1.0–4.0 12.5 Expert retest n= 16 Acceptance 2.250 1.032 2.0 1.250–3.0 1.0–4.0 12.5 Commitment 2.531 0.763 2.25 2.0–3.0 1.5–4.0 3.1 Awareness of influence 2.594 0.800 2.75 2.0–3.0 1.0–4.0 3.1 To analyze the consistency between the evaluations carried out in the TIMB interview, the ICC, SEM and MDC were determined for each index of the interview: (1) between the two evaluations carried out by the principal investigator, (2) between the first evaluation carried out by the investigator and the one performed by the expert, (3) between the second evaluation carried out by the principal investigator and the one implemented by the expert and (4) between the test and retest carried out by expert 2 (Table 3). As can be seen, the values obtained for the ICC show a good consistency level, with a significance of p< 0.001. Likewise, the SEM and MDC values decreased (Table 2). Moreover, the weighted Kappa coefficient showed values that went from moderate to excellent. Regarding the ceiling and floor effects, we must mention that the maximum and minimum possible values in each of the three indices were five points and one point, respectively. In no cases was a score of five reached for any of the three evaluations carried out (principal investigator 1st and 2nd measurement and expert measurement), and neither in the test nor in the retest, indicating the absence of ceiling effect. However, the presence of a possible floor effect (Table 2) was detected in the acceptance index in three evaluations (principal investigator measurement and expert measurement with 32 families and expert test with 16 families). Children 2022,9, 235 9 of 15 Table 3. Intra-class correlation coefficient, standard error of measurement (SEM), minimum detectable change (MDC) and significance of the evaluations carried out by the principal investigator (first and second measurements) and the expert and those obtained in the test and the retest. Index ICC p-Value SEM MDC Weighted Kappa Principal investigator—1st measurement Principal investigator—2nd measurement n= 32 Acceptance 0.950 <0.001 0.219 0.607 0.824 Commitment 0.962 <0.001 0.158 0.438 0.878 Awareness of influence 0.946 <0.001 0.179 0.496 0.832 Principal investigator—1st measurement Expert test n= 32 Acceptance 0.915 <0.001 0.291 0.807 0.753 Commitment 0.879 <0.001 0.322 0.894 0.688 Awareness of influence 0.912 <0.001 0.249 0.690 0.723 Principal investigator—2nd measurement Expert test n= 32 Acceptance 0.929 <0.001 0.276 0.765 0.820 Commitment 0.867 <0.001 0.341 0.944 0.673 Awareness of influence 0.932 <0.001 0.228 0.632 0.820 Expert test-retest n= 16 Acceptance 0.898 <0.001 0.646 1.792 0.777 Commitment 0.841 <0.001 0.657 1.821 0.688 Awareness of influence 0.895 <0.001 0.544 1.507 0.733 The values of Cronbach’s alpha coefficient were 0.577 and 0.647 for the first and second evaluation performed by the principal investigator, respectively, 0.739 for the one conducted by the expert, 0.564 for the test and 0.576 for the retest (p< 0.001). The value of Cronbach’s alpha coefficient did not increase significantly in any case when one of the three indices was eliminated. Subsequently, the mean value of the differences between each pair of measurements and their 95% confidence interval was calculated (Table 4), observing that they were very low values. Table 4. Mean values of the differences between each pair of evaluations and their confidence interval at 95%. Comparison Difference in the Index Mean Confidence Interval at 95% Lower Limit/Upper Limit Principal investigator—1st measurement Principal investigator—2nd measurement n= 32 Acceptance −0.0313 −0.1428/0.0803 Commitment 0.0781 −0.0026/0.1589 Awareness of influence 0.1250 0.0334/0.2166 Principal investigator—1st measurement Expert n= 32 Acceptance −0.0156 −0.1639/0.1326 Commitment 0.0313 −0.1334/0.1959 Awareness of influence 0.1094 −0.0180/0.2367 Principal investigator—2nd measurement Expert n= 32 Acceptance 0.0156 −0.1254/0.1566 Commitment −0.0469 −0.2204/0.1266 Awareness of influence −0.0156 −0.1322/0.1010 Expert test-retest n= 16 Acceptance −0.0625 −0.3176/0.1926 Commitment −0.0938 −0.3551/0.1676 Awareness of influence −0.0625 −0.2773/0.1523