Summary: Introduction: Proactive self-care is a fundamental element of the Participatory Medicine model. Few indices measure self-care, and research about interventions that enhance self-care is sparse. The objective of this study was to develop a simple, direct measure of the dimension of proactive self-care in medical settings for use in research about participatory medical interventions. Methods: An exploratory factor analysis (EFA) was conducted to examine the initial factor structure of the 10-item follow-up questionnaire commonly used in Mindfulness-Based Stress Reduction (MBSR) groups. The sample consisted of 185 participants enrolled in MBSR groups. A confirmatory factors analysis (CFA) was then conducted on part of the sample (n = 94) at MBSR follow-up to test the fit of the model uncovered in the EFA. Results: EFA results revealed a clear 5-item factor assessing what we perceived to be self-care attitude and behavior. The follow-up CFA confirmed a good fit of the data to these items, along with a sixth item we developed. We labeled these six items the Mindful Self-Care Index (MSCI).Conclusion: The MSCI provides a direct measure of proactive self-care and can be reliably employed in studies to help determine the effectiveness of interventions that intend to enhance self-care.
Keywords: Self-care, mindfulness, stress reduction, yoga, meditation, participatory medicine.
Citation: Sunbay-Bilgen Z, Christopher MS, Rogers B. Examining a proactive self-care index in a Mindfulness-Based Stress Reduction (MBSR) program. J Participat Med. 2012 Sept 28; 4:e22.
Published: September 28, 2012.
Competing Interests: The authors have declared that no competing interests exist.
Proactive self-care is at the heart of the model of Participatory Medicine. The current health care system tends to recognize the value of self-care mainly as “disease management” and intends to promote it in the form of patient education offered through pamphlets, web postings, short clinical conversations, and didactic public education classes. Beyond this information-based approach to self-care promotion (and crucial to patients’ personal health) is the need to promote an empowered and proactive mode of self-care. Ferguson recognized that the “art” of empowering patients to engage with their illness proactively was beyond the scope of such traditional supply-side medical information distribution. The author recognized that the source of personal health and well-being is closer to home and flows from the complex matrix of interpersonal relationships with care givers, family and fellow patients. Siegel recognized that, like these interpersonal relationships, our relationship with ourselves is a parallel and powerful source of health and well-being.
A well-recognized mode of enhancing proactive intrapersonal self-care compatible with the model of Participatory Medicine is Mindfulness Based Stress Reduction (MBSR). The course was developed in a hospital setting and intended to complement medical care. The practice of mindfulness cultivates this intrapersonal relationship and engenders a sense of presence and engagement with one’s direct experience of life, even when there is an illness. Chatzisarantis and Hagger showed that through mindfulness, increased awareness to present experience can play a role in the extent to which intentions are transformed into action, and could be a moderating factor in the relationship between intention and behavior.
Studies that measure the degree of change in proactive self-care after an MBSR or similar mindfulness-based intervention have measured self-care indirectly as a derivative of changes in a variety of health-related measures. The overall purpose of our study is to introduce a more direct and reliable measure of self-care that can be used to test the validity of interventions that enhance proactive self-care in the domain of Participatory Medicine.
Reviewing two decades of research on mindfulness in health care we found only one direct measure of self-care. Part of the MBSR program followup questionnaire used in the courses at the University of Massachusetts Medical School’s Center for Mindfulness measures self-care. The 10 questions of part 2 of the questionnaire ask the participant to rate self-care attitude and behavioral changes they have experienced as a direct result of being a participant in an MBSR course.
Despite its use for a number of years, we were unable to locate any information about the psychometric properties of the questionnaire, and it appears to have been used in a more informal fashion to measure self-care after the MBSR course. Therefore, an immediate goal in this study was to examine the factor structure of the 10 items and to determine whether a factor representing participants’ level of engaging in self-care and participation in one’s own health-care would emerge from these items. Our ultimate goal is to have this measure be used as a measure of proactive self-care in the context of MBSR and beyond.
Participants were recruited from 8-week MBSR courses offered through a stress reduction clinic in a healthcare-oriented yoga studio located in a medium-sized city in the state of Oregon from Fall 2007 through Winter 2011 (14 courses in total). All students who were enrolled in the MBSR courses over the 4-year period were invited to complete pre- and post-program self-report measures. A total of 229 participants entered the course; 75% were women and the mean age was 47 (range 16-73, SD = 11.6). Of the 218 participants who completed the program, 185 completed all measures at pre- and post-MBSR and data from these participants were included for analysis. Additionally, we sent a followup questionnaire packet to all 185 participants in Fall 2011, and we received complete data from 94 participants (51%).
MBSR is a systematic 8-week intervention for learning mindfulness meditation. It was created over 30 years ago in a hospital setting as a complement to established medical care. The intervention used in this study was modeled directly on that well-established program. Participants completed an application process and interview prior to admission to the program. They committed to 24 hours of classroom instruction and over 30 hours of homework, 45 minutes per day. Each group met for eight 2.5 hour weekly sessions and for one 6.5 hour retreat on the sixth week of the program.
MBSR is primarily an experiential learning program. Three principal practices are introduced during the program and constitute most of the homework and classroom time for participants. The body-scan meditation involves stepwise guided attention to sensations across all regions of the body from toes to head. Sitting meditation is introduced as a practice of paying attention to the physical experience of the sensations of breathing with a quality of openness to the various other experiences of life that may divert attention: sensations, thoughts, fragrance, emotions, and sounds. Mindful yoga is introduced as a gentle, adapted form of mindful movement designed to offer an appropriate level of physical movement emphasizing direct experience rather than physical performance. Other practices and elements introduced during the program include walking meditation, eating meditation, informal mindfulness of daily activities, and guided meditations such as loving-kindness. Didactic learning includes group dialogue and inquiry mindfulness practice. Participants also learn about the physiology and psychology of stress. Participants in this study completed evaluations and testing for one of the fourteen 8-week MBSR courses from Fall 2007 through Winter 2011 using the measures described below.
MBSR Followup Questionnaire (FQ)
The FQ is a two-part retrospective self-report questionnaire that has been used to assess participant change in MBSR courses at the University of Massachusetts Medical School’s Center for Mindfulness and has also been reported in published research about MBSR. The eight items in part 1 were not evaluated for the purposes of this study. Part 2 includes 10 items used to measure “How much change, if any, has occurred for you in the following attitudes and behaviors as a direct result of your participation in the MBSR Program.” All items are rated on a four-point Likert-type scale (1 = negative change, 2 = no change, 3 = some positive change, 4 = positive change).
Data were collected from a stress-reduction clinic located in Oregon. Participants completed the FQ post-MBSR (after the 8-week intervention) over the 14 MBSR programs from Fall 2007 through Spring 2011. The FQ was then mailed to all participants who completed it at post-MBSR as part of a follow-up survey in Fall 2011. The details of the larger study are described elsewhere.[unpublished data] The mean duration from post-MBSR to followup was 2.5 years.
Using data from post-MBSR (n = 185) responses to the 10 Part 2 FQ, items were subjected to an exploratory factor analysis (EFA) using maximum likelihood (ML) estimation with a promax rotation in SPSS 17.0 (SPSS Inc., 2008). Given that our primary goal was to determine the feasibility of extracting a self-care factor from these 10 items, we evaluated the number of factors, pattern factor loadings, cross-loadings, and communalities to assess item quality. We then submitted the retained items to a confirmatory factor analysis (CFA) using data from followup (n = 94). In the CFA, the model was tested using diagonally weighted least squares (DWLS) estimation with LISREL 8.8. DWLS was used due to the ordinal scale nature of the items and related issues of multivariate non-normality. Additionally, the Satorra-Bentler scaled chi-square χ² (SBχ²) and robust parameter standard errors were estimated. In addition to the SBχ2 statistic, we used the following indices to evaluate overall fit for the model: the comparative fit index (CFI)), the standardized root mean square residual (SRMR), and the root mean square error of approximation (RMSEA) along with its 90% confidence interval (CI).
The EFA analysis on the post-MBSR data (n = 185) yielded 2 factors with eigenvalues greater than 1.0 that cumulatively accounted for 62% of the variance. However, four items either had factor loadings or communalities of less than .4 on any factor after extraction. These four items were deleted and a second factor analysis was conducted, again using ML estimation with a promax rotation. This analysis yielded a two-factor solution, accounting for 66% of the variance after extraction. Five items clearly loaded on the first factor and the sixth item alone loaded on factor two. Because it appeared to be assessing a separate factor, we decided to delete this item and retain the remaining five items that loaded onto a self-care attitude and behavior factor, which we have labeled the Mindful Self-Care Index (MSCI). These five items are presented in Table 1.
After identifying the five-item factor in EFA, to further tap the participatory aspect of self-care in the healthcare realm, we added an additional item to the measure we sent to participants at long-term followup: “Feeling I am able to communicate my needs effectively to my healthcare provider(s).” The specified CFA model consisted of six observed variables (ie, the six items of the self-care measure). The fit of the single factor model was as follows: SBχ²(8) = 8.30, p = .405; CFI = .99, RMSEA = .02 (90% confidence interval = .00-.12), SRMR = .04. Overall, the six-item model provided an excellent fit to the data. All items loadings on the MSCI were statistically significant (p < .05) and they are reported in Table 1. Lastly, the six items also evidenced good internal consistency ( = .83).
We examined the factor structure of an often used followup measure in MBSR to determine whether a factor representing participants’ level of engaging in self-care and participation in one’s own health care would emerge from these items. The EFA of the 10 items on the Center for Mindfulness Follow-up Questionnaire revealed that 5 items loaded on the same factor reflecting self-care attitude and behavior. The addition of a sixth item tapping into the participatory medicine aspect of self-care was justified by the CFA results. This measure of self-care attitude and behavior — the MSCI — was derived from the context of MBSR, an educational intervention that involves increasing the familiarity with present moment experience, which at its heart invites personal and proactive participation. The overall psychometrics and strength of factor loadings for the MSCI is comparable to similar existing measures of self-care related to general health promotion and diabetes management.
In addition to providing possible insights into a mechanism of change underlying health-related outcomes of MBSR, measuring self-care attitude and behavior with the MSCI can be very practical for a wide range of healthcare providers, including primary care physicians, physical therapists, occupational therapists, and mental health professionals. It can be easily adapted to the specific health intervention used, and ideally provide information on the effectiveness of the intervention in terms of enhancing self-care. It is a very brief survey and can be used both to inform the primary healthcare provider as well as the other clinicians who are part of the patients’ interdisciplinary healthcare team (eg, physical therapists, psychologists, occupational therapists). If members of the healthcare team are informed about the patient’s approach to self-care, it might shed light on an important factor that could underlie why a patient does or does not get better.
The MSCI addresses not only the awareness that one needs to take care of oneself, but also actual proactive self-care, change of unhealthy health behaviors, sense of agency around one’s ability to improve own health, and ability to communicate one’s needs with health-care providers. In previous research on the MSCI, we have shown that MBSR participants reported enhanced self-care as a consequence of cultivating awareness through MBSR, and this was related to positive changes in health and decreases in perceived stress levels.[unpublished data] In the same study, self-care was positively correlated with ongoing mindfulness practice and negatively with stress levels for 3 years after participants completed the MBSR program.
Even though MBSR is an 8-week, time-bound intervention, once the skills are learned, people can and do practice it even years later as demonstrated by Miller, Fletcher and Kabat-Zinn. By using the brief MSCI, clinicians can refer patients to mindfulness-based interventions that provide these enduring skills, and are relatively cost-efficient. In line with Bandura’s emphasis on “primacy of self-regulation” (p. 245) for the changing model of healthcare towards one that focuses on health promotion, MBSR is a promising learning intervention that provides the basis for proactive patients to take care of themselves. The MSCI, if used within the context of MBSR, can shed light into a major area of change as a result of cultivating a mindfulness practice.
The results of this study must be interpreted with caution due to a number of limitations. First, this was a study based on one clinic and one community with corresponding demographic limitations, so generalizations to other populations will be limited. Second, although the use of a community-based sample with multiple data collection points was a strength, the sample size was small, and approximately 50% of the sample did not complete the measure at followup. Third, the MBSR FQ was designed as a retrospective questionnaire to be used after an MBSR course. Because it was not designed to be administered pre-MBSR, we were unable to calculate pre-post change data. This is a shortcoming of the scale that we plan to address in a future version of this scale.
Despite these limitations, we believe these results have important implications. With aging populations, the prevalence of chronic diseases is increasing and there are no ultimate “cures” for them. Chronic diseases and other illnesses require patients to self-manage their condition on a daily basis. Acknowledging the active role patients can adopt in their healthcare through their attitude and behaviors of self-care is valuable and hence its practical assessment in clinical settings is essential. Research about interventions in the realm of Participatory Medicine will benefit from the employment of the MSCI and similar instruments that directly measure the crucial element of proactive self-care.
- Bandura A. Primacy of self-regulation in health promotion. Appl Psychol-Int Rev. 2005;54(2). ↩
- Snyderman R. Meditation and the future of health-care. In: Kabat-Zinn J, Davidson RJ, Houshmand Z, eds. Mind’s Own Physician: A Scientific Dialogue with the Dalai Lama on the Healing Power of Meditation. Oakland, CA: New Harbinger Publications; 2011:178-184. ↩
- Ferguson T, e-Patients Scholars Working Group. E-Patients: How They Can Help Us Heal Health Care; 2007. Available at:
http://e-patients.net/e-Patients_White_Paper.pdf. Accessed January 1, 2012. ↩
- Siegel DJ. The Mindful Brain: Reflection and Attunement in the Cultivation of Well-Being. Norton & Company; 2007. ↩
- Kabat-Zinn J. Participatory medicine. J Eur Acad Dermatol Venereol. 2000 Jul;14(4):239-40. ↩
- Chatzisarantis NLD, Hagger MS. Mindfulness and the intention-behavior relationship within the theory of planned behavior. Pers Soc Psychol Bull. 2007;33:663-676. ↩
- Shapiro SL, Brown KW, Biegel GM. Teaching self-care to caregivers: effects of mindfulness-based stress reduction on the mental health of therapists in training. Training Educ Prof Psychol. 2007;1(2):105-115. ↩
- Schure M, Christopher J, Christopher S. Mind-body medicine and the art of self-care: teaching mindfulness to counseling students through yoga, meditation and qigong. J Couns Dev. 2008;86(1):47-56. ↩
- Irving JA, Dobkin PL, Park J. Cultivating mindfulness in health care professionals: a review of empirical studies of mindfulness-based stress reduction (MBSR). Complement Ther Clin Pract. 2009;15(2):61-69. ↩
- Krasner MS, Epstein RM, Beckman H, Suchman AL, Chapman B, Mooney CJ, Quill TE. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302(12):1284-1293. ↩
- Kabat-Zinn J. UMass Medical School Stress Reduction Program followup questionnaire. In: Santorelli S, Kabat-Zinn J, eds. Mindfulness-Based Stress Reduction Curriculum Guide and Supporting Materials. Worcester, MA: Center for Mindfulness in Medicine, Health Care, and Society; 2006. ↩
- Kabat-Zinn J. Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York: Bantam Dell; 1990. ↩
- Kabat-Zinn J. An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results. Gen Hosp Psychiatry. 1982;4:33-47. ↩
- Kabat-Zinn J, Lipworth L, Burney R, Seller R. Four-year follow-up of a meditation-based program for the self-regulation of chronic pain: treatment outcomes and compliance. Clin J Pain. 1987;2(3):159-173. ↩
- Miller JJ, Fletcher K, Kabat-Zinn J. Three-year follow-up and clinical implications of a mindfulness-based stress reduction intervention in the treatment of anxiety disorders. Gen Hosp Psychiatry. 1995;17(3):192-200. ↩
- Shapiro SL, Schwartz GE, Bonner G. Effects of mindfulness-based stress reduction on medical and premedical students. J Behav Med. 1998;21(6):581–99. ↩
- Jöreskog KG, Sörbom D. LISREL 8.80 for Windows [Computer Software]. Lincolnwood, IL: Scientific Software International, Inc.; 2006. ↩
- Satorra A, Bentler PM. Corrections to test statistics and standard errors in covarience structure analysis. In: von Eye A, Clogg CC, eds. Latent Variables Analysis: Applications for Developmental Research. Thousand Oaks, CA: Sage; 1994:399-419. ↩
- Bentler PM. Comparative fit indexes in structural models. Psychol Bull. 1990;107:238–246. ↩
- Steiger JH. Structural model evaluation and modification: an interval estimation approach. Multivariate Behav Res. 1990;25:173-180. ↩
- Lev EL., Owen SV. A measure of self-care self-efficacy. Res. Nurs. Health 1996; 19:421–429. ↩
- La Greca, AM. Brief Manual for the Self Care Inventory. Miami, FL: Author, 1992. ↩
- Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA. 2002;288:2469-2474. ↩
Copyright: © 2012 Zeynep Sunbay-Bilgen, Michael Christopher, and Brant Rogers. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the authors, with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.