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1 Dear Mrs Zainal, Tracking No: SMJ Manuscript Title: Psychometric Properties of the Malay-translated Mindfulness, Attention and Awareness Scale (MAAS) in a Malaysian population Singapore Medical Journal Thank you for submitting the above-referenced manuscript to the Singapore Medical Journal for consideration for publication. We are pleased to advise that the blinded peer review process is completed. The reviewers' and editorial comments are appended below for the authors' consideration. Please revise the manuscript and submit 2 copies (one clean copy and one annotated blinded copy) of the revised submission to the editorial office preferably on/before In the annotated blinded copy, indicate all changes made by underlining the amended portions and also by numbers in the margins of the manuscript. The numbers should correspond to the numbering of your reply to the reviewers' and editorial comments. Please include a blinded cover letter providing a point-by-point reply to the reviewers' and editorial comments, and number each point accordingly. To submit your revision, go to and log in as an Author. You will see a menu item called Submission Needing Revision. You will find your submission record there. Thank you for your support to the Singapore Medical Journal. Yours sincerely, SMJ Editorial Office Singapore Medical Journal Reviewers' and editorial comments: Reviewer #1: This paper presents the psychometric properties of a translated version of the Mindfulness attention and Awareness Scale It is relevant work, useful and applicable for future research However there are some issues that need to be addressed: Introduction 1. Attention to clarity and language is required Some examples: The 3rd line in the first paragraph is unclear: "The mindfulness skill being practiced in treating various types of psychological disorder." 2. The MAAS is introduced in paragraph 2 - it would be important to provide the details about who, when, where and how the Scale was developed. While this information is provided in paragraph 4 under the Methods section, it would be better presented in the Introduction part. 3. Attention to sentence structure is required; this sentence in Paragraph 3 needs to be re-written: "It is a known relationship between higher MAAS scores with lower mood disturbance and stress" 4. In the paragraph 4, rather than "among Malaysian multi-cultural population"..., the Malay version is more likely specific for Malays and a Malay-speaking population. Methods

2 5. The third paragraph needs editing and a grammar check. Some corrected exampls provided: Line 3: "The translated version was carefully checked..." Line 5: "Once clarity and accuracy had been established, two independent researchers did the backtranslation from the Malay version to English..." Line 7: "We then compared the similarity of the 2 versions: the translated English version with the original English version." Line 10: "We revised and modified items in the translated version based on comments received during the pilot study". 6. Information on the MAAS in Para 4 of the Methods section should be presented in the Introduction, as mentioned earlier. Results 7. The choice of approaches to use in deciding on the number of factors to include in a factor analysis can affect the results and credibility. The authors may want to justify why additional criteria such as a scree plot and parallel analysis were not done to reconfirm the fcator structure. 8. A brief explaination could be provided on why the varimax rotation was used and not one of the other types of Factor rotation. Discussion 9. The first paragraph is better placed after the second paragraph in the section. Reviewer #2: This is a sound study which examines the psychometric properties of the MAAS. Below are some comments: 1) Introduction- paragraph two: need to quote references for the whole paragraph on MAAS. 2) Methods- need to quote reference for the statement 'The sample size for validity and reliability testing must be five times the total number of items in the instrument.' 3) It seems more appropriate to state that GHQ and Rosenberg Self Esteem Scale are used to establish predictive validity rather than concurrent validity, as they are of different constructs to MAAS. There are a number of other mindfulness scales such as 'Cognitive and Affective Mindfulness Scale', 'Southampton Mindfulness Questionnaire', 'The Philadelphia Mindfulness Scale' etc, which studies have been done to establish some concurrent validity, though there may not be validated Malay versions. 4) The authors did not state the time lapse between administration of the English version and the Malay version. Please indicate whether they were done during the same session and discuss any implications. Editorial Comments 1. Include line numbers in the manuscript Psychometric Properties of the Malay-translated Mindfulness, Attention and Awareness Scale (MAAS) in a Malaysian population Zainal NZ 1, MD; Yahaya N 2, MSc Nsg, SRN; Subramaniam P 2, DHSci, MEd., SRN

3 Affiliation Authors: From the Department of Nursing Science, Faculty of Medicine, University Malaya, Kuala Lumpur (Nor Aziyan, Dr. Pathmawathi Subramanian), Psychological Medicine Research Group of University Malaya (PARADIGM), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia (Prof. Dr. Nor Zuraida Binti Zainal) Corresponding author: Prof. Dr. Nor Zuraida binti Zainal Psychological Medicine Research Group of University Malaya (PARADIGM), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia ( ABSTRACT OBJECTIVES Interest in mindfulness and its enhancements has quietly exploded in recent years, bringing with it the need for validated instruments to assess mindfulness in the

4 Malaysian population. The study aims to examine the reliability, factor structure and validity of the Malay version of The Mindful Attention Awareness Scale (MAAS) in a group of nursing students. METHOD The MMAAS was forward-backward translated from English to Malay. The translated version was then administered to 266 nursing students. At the same time they were requested to respond to General Health Questionnaire (GHQ) and Rosenberg Self-Esteem Scale (RSES). Principal Component Analysis (PCA) with varimax rotation was performed to explore the factor structure of the MMAAS. Associations of retained factors were estimated by Spearman correlation coefficients. RESULTS Internal consistency reliability of MMAAS was good (Cronbach s α = 0.851) and showed temporal stability in a 3-week period. Principal component analysis suggested three factors labelled as Attention related to general domain, Attention related to physical domain and Attention related to psychological domain. These factors explained 52.09% of the variance. The Malay MAAS and the English version was well correlated (r=0.82, p<0.01). High score in mindfulness was significantly correlated with low level of psychological disorders. CONCLUSIONS The results showed that the Malay-translated Mindful Attention Awareness Scale (MAAS) possesses a three-dimensional factor structure and has satisfactory psychometric properties. We suggest this instrument is appropriate for assessing the mindfulness, awareness and attention in the Malaysian population, especially in young adults. Keywords: reliability, validity, mindfulness, psychometric properties INTRODUCTION Mindfulness is a way of paying attention to one s experience in the present moment, without making judgments about it. (1) Study of mindfulness within the field of psychological and

5 medical research has increased substantially over the last 20 years. The mindfulness therapy being practiced in treating various types of psychological disorder such as psychological distress, depressive, mood disorder, and chronic pain (2) Thistherapy shows improvement in reducing negative psychological impacts such as stress among the individuals as well as promoting significant positive outcomes. (3) The Mindful Attention Awareness Scale (MAAS) was proposedto assessattention and awareness in everyday life. (2) MAAS is commonly used as a mindfulness questionnaire among general populations. MAAS was developed by Brown and Ryan for adults, in normative clinical populations. (2) The tool consists of a 15-item self-reported singlefactor scale that focused on the attention awareness component of the mindfulness construct. This 15-item scale measures the frequency of mindful states in a day-to-day life, using both general and situation-specific statements. Based on a mean of all items, scoring involves calculating mean performance across the 15 items MAAS scores, which range from 1 to 6. The range of total scores is from 15 to 90. Higher scores indicate greater mindfulness. (2) MAAS showsgood psychometric proprieties in terms of validity and reliability. Confirmatory factor analysis supports the uni-dimensional factor structure of the MAAS with factor loading between (3) The MAAS appears to demonstrateacceptableuse in studies examining the role of mindfulness in the psychological well-being of cancer patients. MAAS is well established to have an association with lower mood disturbance and stress. (4) MAAS has been translated into many languages such as Spanish, Chinese, French and Japanese and validated. (7-9) However, the MAAS has not yet been translated and validated into the Malay language among the Malaysian population. Therefore, this study was conducted to validate the psychometric of Malay version of MAAS among Malays and a Malay speaking population.

6 METHODS We carried out a cross-sectional study among diploma nursing students from one of the teaching institutes in Malaysia. Prior to data collection, all the students received information sheets regarding the investigation. A nursing instructor clarified the purpose and methods of the study. Those interested filled in areply slip. They were then contacted by the investigator, to obtain consent to participate in the study. The nursing students were chosen because they were healthy young adults and a suitable population for capturing information on attention and awareness in their daily lives. A convenient sampling method was employedto recruit266 nursing students ranging from first-year to final-year students. The sample size for validity and reliability testing is expected to be at least five times the total number of items in the instrument. (5) The inclusion criteria were that the participants must demonstrate an understanding of the Malay and English language and be able to answer the questions without anyone shelp. We used the back-translation method to create the Malay-translated version of the tool. The original English version of the MAAS instrumentwas first translated into Malay by two authors who are bi-lingual (English and Malay). The translated version was carefully checked for clarity, accuracy, suitability of the language and linguistic errors by two senior nursing educators. Once clarity and accuracy had been established, two independent researchers did the back-translation from the Malay version to English. Both researchers translated the Malay version back into English without prior knowledge of the original English version of MAAS.We then compared the similarity of the 2 versions: the translated English version with theoriginal English version.the translated version was then pilot-tested among 20 staff nurses from the general wards in the hospital. Items in the translated version were revised and

7 modified based on comments received during the pilot study. The finalversionwas reviewedalso to ensure satisfactoryface, semantic, criterion and conceptual equivalence. We collected the socio-demographic information on age, ethnicity, religion, sex and educational level of the participants using a pre-designed questionnaire. The Malay-translated MAAS was given to the 266 students, followed by the original English version. There was no time elapsed between the administration of the English version and the Malay version.completed instruments were then returned to the researcher. A test-retest was conducted after a three-week interval. A 1:1 matching of the same 266 students was carriedout to ensure final sample equivalence to determine the predictive validity. We administered scales for assessing general health and self-esteem. The General Health Questionnaire (GHQ) is widely used internationally and locally to assess mental health status especially in recognition of emotional disorders such as distress. (6) The GHQ-12 has a well-established validity internationally and locally. It is also widelyused in student samples and adolescent populations in the community. Furthermore it is simple, easy to understand, quick and straightforward.the Malay translated version of the General Health Questionnaire-12 (GHQ- 12) used in a group of medical students locally,showed a valid and reliable screening tool in detecting distresswithcronbach s α value of (7) We used Rosenberg Self-Esteem Scale (RSES) to determine self-esteem. (8) The scale is a 10-item Likertscale with items answered on a 5- point scale ranging from1 (strongly agree) to 5 (strongly disagree). (9) It identifies the higher the total score, the higher the self-esteem. The Malay-translated RSES used in a group of high-school students showed a valid and reliable tool to determine self-esteem. (8) The results were analysed using the Statistical Package for Social Sciences version The descriptive statistics were used to determine the baseline characteristic data. The internal consistency of the Malay translated MAAS was assessed using the Cronbach s α

8 coefficient. The test-retest reliability was examined using intra-class correlation (ICC). Principal component analysis (PCA) with varimax rotation method was used to assess the factorial construct of the scale. The varimax rotation is the most common choice used in Factor Extraction Method and the goal of rotation is to simplify and clarify the data structure. The Scree plot test in Figure 1 is done to clearly suggest a multifactorial solution. (10) In order to achieve the number of factors or constructs, Kaiser s criteria was applied (to be factorisable, the Bartlett s test of sphericity must be significant and large, and the Kaiser- Meyer-Olkin (KMO) measure of Sampling Adequacy must be more than 0.6). A newfactor or componentis obtained if the eigenvalue of the factor is more than one. Items were assigned to the factor that produced the highest factor loading. The internal consistency of each factor was confirmed by calculating Cronbach s α. We determined predictive validity between MMAAS, GHQ, and RSES by using Spearman s correlation. RESULTS A total of 266 respondents participated in the study. The mean age was 19.86±1.32 years. Most of them were females (N=258, 97%). The majority of the respondents were Malays (95.1%) and had finished their Form Five education(92.1%). The mean score of each item ranged between 3.45 and Item 12 yielded the highest score which was "I tend to drive somewhere automatically, and later find myself puzzled why I went there while the lowest score was for item 13, I find myself always thinking about the future and the past. Table I shows the comparison of the mean score of each item between the original English MAAS and the Malay version. The meantotal score for MMAAS was 64.12±9.56. Table I Mean score of each item for the original English MAAS and the Malay versions

9 English MAAS Mean+sd Malay MAAS Mean+sd 1. I get emotional and do not realise what is happening until it s over Sayamungkinberemosidantidakmenyedari akanperkaraitusehinggakemudiannya I break or drop things because of carelessness, poor attention or because my mind is on something else Sayaterpecahatautertumpahsesuatubarang keranakecuaian, tidakmemberiperhatian, ataumemikirkanhal lain I find it difficult to pay attention to what is currently going on Sayaberasasusahuntukterusmenumpukanp erhatiankepadaapa yang berlakupadamasaini I tend to walk veryfast to my destination without paying attention to what is happening on the way Sayacenderunguntukberjalandengancepat ketempat yang ditujutanpamenumpukanperhatiankepada apa yang sayaalamipadasepanjangjalan I tend to ignore physical tension or discomfort until it really bothers me Sayacenderunguntuktidakperasanketegan ganfizikalatauketidakselesaansehinggaian yabenar-benarmenarikperhatiansaya I tend to forget people s names immediately after being introduced to them for the first time 7. It s as if I m doing something automatically without me realising it Sayaselaluterlupanamaorangsejurusselepa sdiberitahuuntukkalipertama Iasepertisaya berbuatsesuatusecaraautomatik tanpasayamenyedarinya I tend to rush through my activities without really paying attention to them Sayatergesagesamelakukanaktivititanpabenarbenarmenumpukanperhatiankeatasnya I m too focused on the objective that I wish to achieve until I losedirection on what I m currently doing to achieve it Sayaterlalufokuskepadaobjektif yang sayaingincapaimembuatkansayahilangara hdenganapa yang sayabuatpadamasainiuntukmenujukesitu I tend to carry out my work or duties automatically without realising what I m doing Sayamelakukanpekerjaanatautugasanseca raautomatik, tanpamenyedariapa yang sayalakukan I find myself listening to others with only one ear while carrying out other tasks at the same time Sayamendapatidirisayamendengarpercaka panseseorangdengansebelahtelinga, danmelakukanperkara lain dalammasa yang sama I tend to drive somewhere automatically, and later find myself puzzled why I went there Sayamemandukesesuatutempatsecarapan duanautomatik, dankemudiannyakehairanankenapasayake sana I find myself always thinking about the future and the past Sayamendapatidirisayaasyikmemikirkanp erkara di masahadapandanmasalampau I find myself doing things without paying attention Sayamendapatidirisayamelakukansesuatu perkaratanpa member perhatian I have meals without realising what I m eating Sayamengambilkudapantanpamenyedari yang sayasedangmakan

10 MMAAS exhibits good internal consistency, with overallcronbach s α coefficient of When we deleted each item, the Cronbach s α ranged from 0.83 to 0.85.With regards to temporal stability, the test re-test coefficient for MMAAS after 3 weeks was 0.85(95% CI: 0.82, 0.88). In the preliminary analysis, the Bartlett s test of sphericity was significant and large (p=0.000). The KMO measure of Sampling Adequacy was Therefore, it was appropriate to proceed to exploratory factor analysis. We used Principal Component Analysis (PCA). Three factors were extracted (eigenvalue > 1.00). The factors combined to account for 52.09% of the variance (Table II). All items loaded 0.30 or above; there were a few multiple cross-loading. Cronbach s α for factor 1 was 0.67, factor 2 was 0.74 and factor 3 was Factor 1 accounted for 34.33% of the variance and comprised of 7 items. This factorwas labelled as attention related to generaldomain. Factor 2 accounted for 9.85% of the variance and comprised of 5 items. This factorwas labelled as attention related to the physicaldomain. Factor 3 accounted for 7.91% of the variance and comprised of 3 items.this factorwaslabelledas attention related to psychological domain. Table II Factor loadings for Malay translated Mindful Attention Awareness Scale (MMAAS) MMAAS Items Factor 1 Factor 2 Factor 3 Item Item Item Item Item Item Item Item Item Item Item Item Item Item Item Cronbach s α Eigenvalue Explained variance

11 Fig. 1 Scree Plot Chart of the MAAS The Spearman s correlation between the Malay-translated version (MMAAS) and the original English Mindfulness, Attention and Awareness Scale (MAAS), General Health Questionnaire (GHQ) and Rosenberg Self-Esteem are shown in Table III. The mean total score for GHQ was 1.40±2.03andthe meantotal score for RSES was 21.42±3.34. Parallel reliability of MMAAS and EMAAS was good as shown by Spearman s correlation of 0.82 (p<0.01). The Total, Factor 1, Factor 2 and Factor 3 were inversely correlated with GHQ. The results suggested that the higher the MAAS score, the lower the GHQ score. However, the results also showed that the Total, Factor 1, Factor 2 and Factor 3 were not significantly correlated with RSES (Table III). Table III Correlation (Spearman s Rho) between MMAAS, GHQ and RSES

12 MMAAS Factor 1 MMAAS Factor 2 MMAAS Factor 3 Total MMAAS MMAAS Factor 1 MMAAS Factor 2 MMAAS GHQ RSES MMAAS TOTAL EMAAS Factor 3 MMAAS 0.55** 0.39** 0.86** 0.73** -0.21* ** 0.84** 0.65** -0.24** ** 0.58** -0.35** ** -0.31** 0.06 MMAAS= Malay Mindfulness, Attention and Awareness Scale EMAAS = English Mindfulness, Attention and Awareness Scale GHQ= General Health Questionnaire RSES=Rosenberg self-esteem Scale *p<0.05 **p<0.01 DISCUSSION The psychometric analysis showed that the Malay-translated MAAS was a reliable tool to be used among this group. All the items of the Malay- translated MAAS indicated strong internal consistencies which the Cronbach s α ranged from These findings are consistent with the original MAAS which also presented with good internal consistencies with Cronbach s α ranging from (4)After a 3-week interval the test-retest reliability was still high and remarkably stable. At face value, the Malay-translated MAAS appears as a reasonable and understandable scale used in a group of nursing students. From the descriptive analysis, the students reportedof paying more attention while driving somewhere but paying less attention thinking of their future or the past. However, on the whole, the score showed a tendency for students to be more aware in their daily activities rather than acting on autopilot.

13 The results of this study using PCA were inconsistent with those reported in previous studies.(2-4, 6, 11-14)Those studies found that the 15-item MAAS had adequate fit to the onedimensional factor structure. On the contrary, we found a 3-dimensional model from the exploration. They were three distinguishing factors which we labelled as Attention related to general domain, Attention related to physical domain and Attention related to psychological domain. Factor 1 consisted of 7 items (Items 9, 10, 11, 12, 13, 14, and 15) and accounted for 34.3% of the variance. Factor 2 (Items 4, 5, 6, 7, and 8) accounted for 9.8% and Factor 3 (Items 1, 2, and 3) accounted for 7.9% of the variance. Each Factor was loaded strongly with factor loadings from 0.45 to 0.80 and yielded good reliability (Cronbach s α > 0.66) indicating a high degree of internal consistency. Items 8, 9, 10, 11, 13 and 14 hadmultiple cross-loading.they were loaded greater than 0.3 mainly in Factor 1 and Factor 3 except for Item 10 and item 11. Theywere also loaded in Factor 2.However, they strongly loaded in Factor 1 except for Item 8. Hence we propose a 3-dimensional model for the Malaytranslated MAAS based on this exploratory factor analysis. A methodological review reported that a uni-dimensional scale has the tendency to generate artifactual difficulty factors when using exploratory analysis. (15) Another possible reason that this study produced a threedimensional model, different from other studies, is due to cultural differences. This Malay group might have had a different understanding of mindfulness. Even though they gave almost similar responses in both the Malay and English versions, but it is not possible to say whether they comprehend the same concept of mindfulness compared to other cultures. The Malay-translated MAAS also showed good concurrent validity as evidenced by significant moderate inverse correlation results between Malay-translated MAAS and GHQ. These preliminary results showed that individuals who are distressed are more likely to have poor attention and awareness. Looking at it from another perspective, individuals with higher mindfulness tend to experience more positive psychological wellbeing. (16) On the contrary,

14 wefound no significant correlationbetween the Malay-translated MAAS score and self-esteem in this sample. This is inconsistent with the findings in a group of adolescents with higher mindfulness who rated higher self-esteem. (11) There were a few limitations in this study. The sample was from a single teaching hospital in Malaysia and was homogenous.therefore, it is not necessarily representative of the general population. Furthermore, this instrument was a self-reported questionnaire of mindfulness. The responders might have had difficulties being aware of their experience at the present moment. They might have given answers describing what they should do instead. The study findings showed that the psychometric properties of the Malay-translated MAAS are acceptable, and these instruments may be used for assessing mindfulness, awareness and attention in the Malaysian population, especially in young adults. The results found that the factor structure analyses in this study should be examined in future studies.

15 ACKNOWLEDGEMENTS This study was supported by a research grant (no. UMRP2102/012A) from the Psychological Medicine Research Group of University Malaya (PARADIGM) Faculty of Medicine, University of Malaya, Malaysia. The authors are also grateful to all participants for their time and support.

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