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The Relationship of Mindfulness and Mindfulness-Related Practices with Alcohol Use among Hispanics/Latinx Christine Vinci , Lauren Malkhasyan , Vani N. Simmons , Virmarie Correa-Fernandez PII: DOI: Reference:
S0165-1781(19)31674-9 https://doi.org/10.1016/j.psychres.2020.112774 PSY 112774
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Psychiatry Research
Received date: Revised date: Accepted date:
2 August 2019 3 December 2019 5 January 2020
Please cite this article as: Christine Vinci , Lauren Malkhasyan , Vani N. Simmons , Virmarie Correa-Fernandez , The Relationship of Mindfulness and Mindfulness-Related Practices with Alcohol Use among Hispanics/Latinx, Psychiatry Research (2020), doi: https://doi.org/10.1016/j.psychres.2020.112774
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier B.V.
1 Highlights No differences emerged among H/L sub-ethnicities on mindfulness-related practices. Spiritual practices were associated with less problematic alcohol use. Higher trait mindfulness was associated with less problematic alcohol use. Mindfulness appears protective regarding problematic alcohol use among H/L.
2 The Relationship of Mindfulness and Mindfulness-Related Practices with Alcohol Use among Hispanics/Latinx
Christine Vinci,1 Lauren Malkhasyan,1 Vani N. Simmons,1 & Virmarie Correa-Fernandez2
1
2
Moffitt Cancer Center Tampa, FL 33617
University of Houston Houston, TX 77004
Corresponding Author Christine Vinci, Ph.D. Moffitt Cancer Center Health Outcomes and Behavior 4115 E Fowler Ave. Tampa, FL 33617 Phone: 813-745-5421 Fax: 813-449-6871 Email: [email protected]
Declaration of Interest: None.
Abstract Hispanics/Latinx (H/Ls) are the largest ethnic minority group in the U.S., and three of the four leading causes of death are associated with problematic alcohol use. This study examined the relationship between mindfulness and alcohol use among H/Ls and whether differences emerged by sub-ethnicity. Participants (N=341; 49.7% female; average age=28.57) were H/Ls currently living in the U.S. Survey questions were answered online in English or Spanish. Participants
3 primarily endorsed engaging in informal mindfulness practices (47.5%), spiritual practices (25.2%), and mindfulness meditation (24.6%). No significant differences emerged among H/L sub-ethnicities. Spiritual practices and higher mindfulness were associated with less problematic alcohol use among the entire sample. Similar results were found among drinkers-only. Findings shed light on commonly used mindfulness practices and indicate that very few differences emerge among H/L sub-ethnicities on mindfulness practices and general mindfulness. The delivery/tailoring of mindfulness-based interventions (MBIs) may not need to differ amongst H/L sub-ethnicities in the U.S. Aspects of mindfulness appear protective regarding problematic alcohol use, suggesting that future MBIs that increase mindfulness should be explored for this population. Keywords: Hispanics/Latinx; mindfulness; alcohol use; intervention development; subethnicities
4 1. Introduction Hispanics/Latinx (H/Ls) currently comprise about 17% of the U.S. population, and this number is expected to grow to 30% by 2060 (U.S. Census Bureau, 2015; Colby & Ortman, 2015). Three of the four leading causes of death among H/Ls are associated with problematic alcohol use (e.g., cancer, heart disease, and stroke; Larsson et al., 2016; Nelson et al., 2013; Siegel et al., 2015; Whitman et al., 2017). H/Ls also have higher incident rates of liver disease, and often develop liver disease at a younger age and have a more severe presentation than nonH/Ls (Carrion et al., 2011; Levy et al., 2015). Some of these findings might be related to the notion that although H/Ls as a group are less likely to drink than non-H/Ls in the U.S., among those H/Ls who do drink alcohol, they do so at higher rates than non-H/Ls (CDC, 2014). Furthermore, H/Ls report lower substance use treatment utilization, including for alcohol use problems (Alvarez et al., 2007; Chartier & Caetano, 2010). Because heavy alcohol use among H/Ls can result in high rates of morbidity and mortality, interventions designed to decrease use would likely benefit this population. Mindfulness has been associated with decreased alcohol use (Bowen et al., 2006; Brewer et al., 2009; Wupperman et al., 2012; Zgierska et al., 2008) and has been defined as directed, flexible cognitive processing that allows an individual to observe thoughts and emotions, as opposed to reacting to them (Breslin et al., 2002). A central factor in this process is the ability to direct attention in a particular, purposeful way without judgment (Kabat-Zinn, 1994; Shapiro et al., 2006). Through mindfulness practices, individuals are taught to notice unpleasant experiences (e.g., thoughts, emotions), without immediately trying to get rid of or change them. Through these processes, individuals can alter automatic cognitive processes, and in turn increase cognitive flexibility (i.e., the experience is viewed from an outside, objective
5 perspective; Shapiro et al., 2006; Roemer & Orsillo, 2003; Teasdale et al., 1995; Teasdale et al., 2000; Williams et al., 2000). In other words, mindfulness can allow a person to shift out of automatic pilot and decrease reactivity, which can be especially helpful when trying to change a habitual behavior pattern. Mindfulness can be defined as a general trait that an individual has and demonstrates in their day-to-day life (Baer et al., 2006). For example, an individual high in trait mindfulness would naturally pay attention to a given activity (e.g., driving to work), notice the impact of their emotions on their body (e.g., shoulder tension), or even be aware of common patterns of their thoughts (e.g., “planning” thoughts; “worry” thoughts). In addition to measuring trait mindfulness, researchers can also collect data on mindfulness practices that someone engages in (e.g., mindful meditation; yoga). Mindfulness-based interventions (MBIs) consist of several mindfulness practices that an individual learns over the course of several weeks (e.g., Bowen et al., 2011). The existing theoretical and empirical literature on mindfulness suggests that specific mechanisms underlie MBIs for alcohol use, including increased attention/awareness, the ability to shift out of “autopilot”, and a general increased tolerance of unpleasant experiences (Garland et al., 2014; Karyadi et al., 2014; Witkiewitz et al., 2014). However, we know very little about the impacts of these interventions or mechanisms among H/Ls. In fact, to our knowledge it appears that no prior research has specifically examined a mindfulness-based intervention that addresses alcohol use for H/Ls. Thus, prior to implementing such interventions in this population, it is important to first assess current use of these practices among H/Ls and to explore whether practices might differ among sub-ethnicities (e.g., Mexican vs Cuban). Such information is vital to inform the development/modification of MBIs for a diverse group of H/Ls, specifically with regards to facilitating treatment utilization.
6 Prior studies have revealed frequent use of Complementary and Alternative Medicine (CAM; e.g., herbs, spiritual healing) for health concerns among H/L populations due to unique cultural practices and H/Ls general approach to formal healthcare (Ortiz et al., 2007; Garces et al., 2006). Although mindfulness-based approaches are a category that often falls under CAM, very little research has been conducted on the use of various mindfulness-related practices among H/Ls. For instance, although we know that when compared to non-H/Ls in the U.S. H/Ls report engaging in fewer mindfulness-based activities (e.g., yoga, tai chi; Olano et al., 2015), we do not have in-depth understanding about engagement in mindfulness practices (e.g., length of time, reasons for practice), how these practices relate to health behaviors such as alcohol use, and how these may (or may not) differ by sub-ethnicity (e.g., Mexican vs. Cuban vs. Puerto Rican). Although H/Ls tend to be viewed as a homogenous group, differences have arisen in terms of prevalence of certain health behaviors, including alcohol use (Caetano et al., 2009). For instance, US-born Puerto Ricans and Mexicans have higher rates of alcohol dependence than Cubans (Caetano et al., 2009). Thus, it is important to consider specific sub-ethnicities within the context of intervention development. It is also unclear how trait mindfulness (one’s general level of mindfulness in day-to-day life) is related to problematic alcohol use among H/Ls. It would be expected that higher trait mindfulness would be associated with lower problematic alcohol use, as is typically found in other populations (Karyadi et al., 2014; Vinci et al., 2016b). This paper attempts to answer these questions in an effort to inform treatment development for H/Ls. To better understand mindfulness and alcohol use among H/Ls, we first present data on the current use of mindfulness-related practices and overall levels of trait mindfulness and problematic alcohol use, followed by how these may differ among sub-ethnicities. Second, we hypothesized that higher trait mindfulness would be associated with less problematic alcohol use.
7 2. Method 2.1 Participants Participants in this study met the following eligibility criteria: 18 years of age or older, self-identified as Hispanic/Latinx, were able to speak and read in either English or Spanish, currently lived in the U.S., and were able to provide informed consent. 2.2 Procedure The online survey was available from October 2017 to April 2018. All participants were recruited through advertisements in both English and Spanish presented on various social media platforms (e.g., Facebook, Craigslist and Reddit). Study ads included a survey link that brought participants to the informed consent page. Following completing informed consent, participants answered the inclusion criteria questions, and if eligible, began the survey that took about 15 minutes to complete. Participants who completed the survey had the option to provide their email address to be entered into a drawing for the chance to win a $100 gift card. All procedures were approved by the institution’s IRB. 2.3 Measures The entire survey, including study advertisements, informed consent, and questionnaires, was available in either English or Spanish. These documents were translated from English to Spanish in an iterative process. They were first translated from English to Spanish by a certified translator, and then checked by two native speakers. Feedback from the native speakers was then discussed with the translator, and final edits were made. The following measures were analyzed as part of the current study. 2.3.1 Demographics. Demographic information was collected from all participants, and included information related to gender, age, sexual orientation, marital status, education, and
8 household income. Participants were also asked, “Culturally, which group do you most identify with?” Response choices included: Mexican, Puerto Rican, Cuban, Dominican, Central American, South American, and Other. 2.3.2 Alcohol Use Disorders Identification Test-Concise (AUDIT-C). Participants answered questions regarding their alcohol use on the AUDIT-C, which assessed quantity, frequency and binge drinking. Interpretation of scores vary by gender, and include a score of > 3 being considered problematic alcohol use for women, and a score of > 4 being considered problematic alcohol use for men (Bush et al., 1998; Bradley et al., 2003). The AUDIT-C is considered an effective measure of alcohol use among Latinx individuals (Frank et al., 2008). Cronbach’s alpha for the AUDIT-C in current study was .71. 2.3.3 Mindful Attention Awareness Scale (MAAS). The MAAS is a 15-item questionnaire that measures the attentional component of mindfulness (Brown & Ryan, 2003). Participants responded on a 6-point Likert scale ranging from 1 (almost always) to 6 (almost never), with higher scores being indicative of greater levels of trait mindfulness. The MAAS has demonstrated reliability and validity in a bilingual English-Spanish population (Johnson et al., 2014). Cronbach’s alpha for the MAAS in current study was .88. 2.3.4 Five Facet Mindfulness Questionnaire (FFMQ). The non-judging subscale of the FFMQ was used to assess the ability of participants to approach emotions and thoughts with a sense of nonjudgment/acceptance (Baer et al., 2006). This nonjudging subscale consisted of 8 items rated on a Likert scale from 1 (never or very rarely true) to 5 (very often or always true). Items are reversed scored on this subscale, such that higher scores result in higher mindfulness. We chose to include only this subscale of the FFMQ to reduce participant burden. Further, given the MAAS primarily targets the attentional component of mindfulness, the FFMQ nonjudging
9 subscale provides additional information on mindfulness not captured in that measure. The FFMQ has been shown to effectively measure mindfulness in Spanish samples (Cebolla et al., 2012). Cronbach’s alpha for the FFMQ-nonjudging subscale in the current study was .93. 2.3.5 Mindfulness-Related Practice. Participants were asked to identify their familiarity with various mindfulness-related practices. We use the term “mindfulness-related practices”, as it is possible that although an individual might endorse a certain practice, we do not know whether they engage in it mindfulness based on the survey results. They were asked: “Below is a list of categories of practices that you may or may not have done in your life. Please check what practices you’ve done: a) tai chi/qui gong, b) yoga, c) mindfulness meditation (for example, formal seated or walking practice with a primary focus on breathing; Vipassana; MindfulnessBased Stress Reduction), d) mantra meditation (for example, transcendental meditation), e) devotional/spiritual meditation (for example, prayer), and f) informal mindfulness practice (for example, trying to focus your attention only on a certain activities, such as eating, driving, washing the dishes, etc.).” Of those choices, if a participant did endorse current practice, they were then asked to identify how often they engaged in each practice from the following options: a) less than 6 months, b) 7 months – 2 years, c) 3 – 5 years, d) 6 – 10 years, or e) 11 or more years. Participants were then asked to indicate their primary reason for currently engaging in the practices they checked off: a) to help manage stress, b) to change some behavior (for example, to lose weight, quit smoking, etc.), c) because they enjoyed it, or d) because it was related to their religious/spiritual beliefs. They were able to select as many options as applicable. 2.4 Analytic Plan
10 Descriptive analyses are presented to describe the demographics, alcohol use, mindfulnessrelated practices, and trait mindfulness of the sample. Analysis of Variance (ANOVA) was used when examining sub-ethnic group differences on mindfulness practices and trait mindfulness. Hierarchical linear regressions were implemented for the mindfulness and alcohol use analyses; relevant covariates (described below) were included in these models. 3. Results 3.1 Sample Characteristics Participants (N = 341) were 49.7% female with an average age of 28.57 (SD = 11.49). About 12% chose to complete the survey in Spanish. Participants who completed the survey in Spanish had significantly higher MAAS scores than those who completed the survey in English; therefore this variable was controlled for in all subsequent analyses. There were no significant group differences on the FFMQ or AUDIT-C, based on the language the survey was completed in. When asked “Culturally, which group do you most identify with?” participants reported: Mexican (32.3%), South American (22.9%), Cuban (12%), Puerto Rican (11.4%), Central American (7.9%), Dominican (2.9%), Other (7.9%), and choose not to answer (2.6%). The majority of the sample indicated their race as White (73%), followed by more than one race (7%), and Other (7.6%). The sample was 19.4% LGBQ (Lesbian, Gay, Bisexual, Queer) and 33.4% were married or living with a partner. Regarding education and income, 96.8% reported having a high school diploma or greater (24.3% of the sample reported having an undergraduate degree) and 41.6% reported less than a $30,000 annual household income. Average scores were as follows for the MAAS: 3.68 (SD = .95) and FFMQ: 3.07 (SD = 1.09). On the AUDIT-C, the entire sample reported an average score of 2.58 (SD = 2.52). When excluding those who endorsed never drinking (thus only including alcohol drinkers, n = 211), the
11 average score was 3.59 (SD = 2.29). Female drinkers had an average of 3.11 (SD = 1.95) and male drinkers 3.97 (SD = 2.45). Table 1 presents AUDIT-C scores by sub-ethnicity. H/L subethnicities did not significantly differ on the AUDIT-C (both when examining the entire sample and for alcohol drinkers-only). We re-ran this analysis including only those groups with larger sample sizes (i.e., Mexican, Puerto Rican, Cuban, South American), and results were the same. 3.2 Mindfulness-related Practice Among mindfulness-related practices, participants endorsed currently engaging in informal mindfulness practices (47.5%), spiritual practices (25.2%), mindfulness meditation (24.6%), yoga (14.1%), mantra meditation (6.7%), and tai chi (1.2%). Results of an ANOVA indicated that there were no significant differences among H/L sub-ethnicities on mindfulness practices or general level of trait mindfulness on the MAAS or FFMQ. See Table 2 for a breakdown of mindfulness practices by sub-ethnicity. Among the subset of participants who endorsed current mindfulness-related practices, we further examined those who endorsed informal (n = 159), spiritual (n = 83), and mindfulness meditation (n = 81), given these were the practices most commonly reported. Regarding informal mindfulness practice and mindfulness meditation, most participants had been practicing for 7 months – 2 years. For spiritual practices, most reported practicing for 11 or more years. Table 3 presents a more detailed breakdown of the frequency of these practices. Regarding why participants currently engaged in any mindfulness-related practice, they reported the following (could select more than one): to manage stress (50.1%), for enjoyment (38.7%), to change some behavior (25.8%), for religious/spiritual purposes (23.8%), and other (4.4%). 3.3 Mindfulness and Alcohol Use
12 Each mindfulness-related practice (dichotomized as never/do not currently practice vs. currently practice) was individually examined as a predictor of alcohol use with hierarchical linear regression. Gender and education were added as covariates in each model, as significant differences emerged between groups on the outcome variable of AUDIT-C score. As mentioned above, language the survey was completed in was also included as a covariate. Results indicated that only spiritual practices were associated with less problematic alcohol use, F(4,293) = 5.11, p = .001 (spiritual practices: B = -.70, t = -2.19, p = .029). No other mindfulness-related practice was significantly associated with alcohol use. Higher trait mindfulness (according to the MAAS) was also associated with less problematic alcohol use, F(4,293) = 6.79, p = .001 (MAAS: B = .50, t = -3.28, p = .001). The FFMQ model was not significant. These same analyses were conducted after selecting only those participants who endorsed drinking alcohol, thus excluding never drinkers. Results indicated that no specific mindfulnessrelated practices were associated with alcohol use. Regarding trait mindfulness, higher mindfulness was associated with less problematic alcohol use according to the MAAS, F(4,209) = 6.03, p = .001 (MAAS: B = -.47, t = -2.80, p = .006). The FFMQ model was not significant. 4. Discussion This paper presents some of the first data on mindfulness-related practices and alcohol use among H/L sub-ethnicities. Findings indicated that informal mindfulness practices were the most frequently endorsed, with tai chi being the least. We did not find significant differences in mindfulness practices by sub-ethnicity, although variability did exist (e.g., for yoga, there was a range from 0% for Dominican and 19.5% for Cuban). Of participants who reported currently engaging in mindfulness-related practices, most reported using them to manage stress, followed by for enjoyment. Among the entire sample, engagement in spiritual practices and high trait
13 mindfulness was associated with less problematic alcohol use. Among alcohol users only, high trait mindfulness was also associated with less problematic alcohol use. These results have direct implications for intervention development among H/Ls. To our knowledge, no prior studies have presented a detailed description of mindfulnessrelated practices among H/L sub-ethnicities. Our results suggest that a range of practices are utilized by this population, with informal meditation, spiritual practices, and mindfulness meditation being the most common. Such findings suggest that when considering what practices to incorporate into MBIs, H/L sub-ethnic groups have similar experiences with mindfulness practices and therefore it may not be necessary to tailor practices to certain sub-ethnicities. Further, informal mindfulness and mindfulness meditations are central to most MBIs (Bowen et al., 2011; Kabat-Zinn, 1990; Kuyken et al., 2008; Teasdale et al., 2000), potentially making the adaptation of existing MBIs acceptable for this population. Researchers developing MBIs may also consider how to support existing spiritual practices through mindfulness practices. Previous research has shown that a sample of predominately African American participants reported that mindfulness practices could supplement their religion and spirituality (Spears et al., 2017). These data should be interpreted all while keeping in mind that we only assessed experience with mindfulness practices, not preference. Future research on intervention development should consider preferences for certain mindfulness practices among H/Ls. Regarding alcohol use, it appears that engagement in spiritual practices serve as a protective factor, which is consistent with extant literature (Kendler et al., 2003; Leigh et al., 2005; Witkiewitz et al., 2016). Our study did not inquire about what spiritual practices were utilized. Extant literature has shown that different spiritual practices (e.g., high thankfulness and viewing God as a judge) are associated with lower alcohol dependence (Kendler et al., 2003);
14 thus, future research among H/Ls could further assess specific spiritual practices to inform treatment development. In both the entire sample and among alcohol users only, high trait mindfulness (according to the MAAS) was associated with less problematic alcohol use. To our knowledge, this is the first analysis to examine the role of trait mindfulness and alcohol use among a large sample of H/Ls. This finding in particular has implications for intervention development, as MBIs often aim to increase trait mindfulness to impact psychosocial outcomes. Given we specifically examined alcohol use in the current study, future research should examine whether a MBI targeting alcohol use among H/Ls might be useful in increasing trait mindfulness, thus impacting problematic drinking. Future research in this area is further supported by participants’ responses stating that the main reason why they currently engage in mindfulness practices is to manage stress. Given H/Ls have lower substance use treatment utilization than other racial/ethnic groups (Alvarez et al., 2007; Chartier et al., 2010), it is important to consider specific aspects of treatment that might be already practiced among H/Ls and incorporate them into alcohol use treatment programs. The nonjudging facet of the FFMQ was not associated with problematic drinking. Previous research in non-H/L populations have found mixed results regarding nonjudging and alcohol use (Bodenlos et al., 2015; Fernandez et al., 2014; Murphy & MacKillop, 2012; Roos et al., 2016; Vinci et al., 2016a), with many studies finding no significant association (Bodenlos et al., 2015; Fernadez et al., 2014; Roos et al., 2016). Possible explanations may include the use of the FFMQ nonjudging subscale itself, or, that the assessment of alcohol use was limited (e.g., the AUDIT-C captures problematic use, not negative consequences related to use). Future research
15 should attempt to replicate these results among H/L, and also consider the utilization of other assessments of nonjudging and alcohol-related variables. Limitations of this study should be noted. First, we do not know how participants selfdefined each mindfulness-related practice. Although the answer choices included examples, it is not entirely clear how “spiritual practices” was interpreted, for instance. Participants could even engage in these practices in ways that are inconsistent with mindfulness. We also only examined the presence/absence of specific practices, and not the frequency/quantity of each practice. As such, it is possible that frequency and/or duration are related to alcohol use; future research should ask these additional questions about mindfulness practices in order to fully understand these relationships. Second, we utilized the MAAS and the FFMQ subscale of nonjudging to capture trait mindfulness, and therefore, future research is needed to examine how these other aspects of mindfulness (e.g., nonreactivity, compassion) were not collected. Thus, future research is needed to examine whether or how these other components of mindfulness relate to alcohol use among Latinx individuals. Third, characteristics of this sample (e.g., younger age) may limit the generalizability of findings to other H/Ls in the U.S. Third, for some subethnicities (e.g., Dominican), we had low sample sizes. Thus, it is possible that if group differences do exist, we were not able to capture them. For example, we did not find that alcohol use differed by sub-ethnicity, which has been reported previously (Caetano et al., 2009). However, even when limiting the analysis to those groups with larger sample sizes, group differences did not exist on this outcome. Investigators who are interested in developing MBIs for a particular sub-ethnicity that had a low sample size in the current study may want to conduct a separate study targeting that specific group in order to obtain an adequate number of participants. Despite these limitations, this study is one of the first to present an analysis of
16 mindfulness-related practices and alcohol use among specific H/Ls sub-ethnicities. Furthermore, the sample consisted of a large number of H/Ls, with both males and females equally represented, from across the U.S. In sum, these data present an overview of the mindfulness-related practices engaged in by H/Ls in the U.S. Importantly, spiritual practices and trait mindfulness were associated with less problematic alcohol use. Such information has the potential to inform interventions for problematic health behaviors (e.g., alcohol use) among H/Ls. Future research is needed to examine preferences for mindfulness-based practices among those with varying levels of familiarity with mindfulness in order to develop/modify MBIs for this population.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author Statement CV was responsible for the conceptualization of the manuscript, oversaw data collection and analysis, and wrote the first draft of the paper. LM assisted in data collection and the writing and editing of the manuscript. VS assisted in designing the study and in writing and editing the manuscript. VC assisted in designing the study and in writing and editing the manuscript. Declaration of Interest Declarations of interest: none.
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21 associations between mindfulness facets and alcohol outcomes among college students. Psychology of Addictive Behavior, 29, 176-183. Shapiro, S. L., Carlson, L. E., Astin, J. A., & Freedman, B., 2006. Mechanisms of mindfulness. Journal of Clinical Psychology, 62(3), 373-386. Siegel, R. L., Fedewa, S. A., Miller, K.D., Goding‐Sauer, A., Pinheiro, P.S., Martinez‐Tyson, D., & Jemal, A., 2015. Cancer statistics for Hispanics/Latinos, 2015. CA: A Cancer Journal for Clinicians, 65, 457-480. Spears, C. A., Houchins, S. C., Bamatter, W. P., Barrueco, S., Hoover, D. S., & Perskaudas, R., 2017. Perceptions of mindfulness in a low-income, primarily African American treatment-seeking sample. Mindfulness, 8, 1-12. Teasdale, J. D., Segal, Z., & Williams, J.M.G., 1985. How does cognitive therapy prevent depressive relapse and why should attentional control (mindfulness) training help? Behaviour Research and Therapy, 33(1), 25-39. Teasdale, J. D., Segal, Z. V., Williams, J. M. G., Ridgeway, V. A., Soulsby, J. M., & Lau, M. A., 2000. Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology, 68(4), 615-623. U.S. Census Bureau, 2015. Population Estimates. Vinci C., Peltier, M., Waldo, K., Kinsaul, J., Shah, S., Coffey, S. F., & Copeland, A. L., 2016a. Examination of trait impulsivity on the response to a brief mindfulness intervention among college student drinkers. Psychiatry Research, 242, 365-374. Vinci, C. Spears, C. A., Peltier, M. R., & Copeland, A. L., 2016b. Drinking motives mediate the relationship between facets of mindfulness and problematic alcohol use. Mindfulness, 7, 754-763.
22 Whitman, I. R., Agarwal, V., Nah, G., Dukes, J. W., Vittinghoff, E., Dewland, T. A., & Marcus, G. M., 2017. Alcohol abuse and cardiac disease. Journal of the American College of Cardiology, 69, 13-24. Williams, J. M. G., Teasdale, J. D., Segal, Z. V., & Soulsby, J., 2000. Mindfulness-based cognitive therapy reduces overgeneral autobiographical memory in formerly depressed patients. Journal of Abnormal Psychology, 109(1), 150-155. Witkiewitz, K., Bowen, S., Harrop, E.N., Douglas, H., Enkema, M., & Sedgwick, C., 2014. Mindfulness-based treatment to prevent addictive behavior relapse: Theoretical models and hypothesized mechanisms of change. Substance Use and Misuse, 49(5):513-524. Witkiewitz, K., McCallion, E., & Kirouac, M., 2016. Religious affiliation and spiritual practices: An examination of the role of spirituality in alcohol use and alcohol use disorder. Alcohol Research Current Reviews, 38, 55-58. Wupperman, P., Marlatt, G. A., Cunningham, A., Bowen, S., Berking, M., Mulvihill‐Rivera, N., & Easton, C., 2012. Mindfulness and modification therapy for behavioral dysregulation: Results from a pilot study targeting alcohol use and aggression in women. Journal of Clinical Psychology, 68, 50-66. Zgierska, A., Rabago, D., Zuelsdorff, M., Coe, C., Miller, M., & Fleming, M., 2008. Mindfulness meditation for alcohol relapse prevention: A feasibility pilot study. Journal of Addictive Medicine, 2, 165-173.
23 Table 1. Alcohol Use by Sub-ethnicity Entire Sample
Mexican Puerto Rican Cuban Dominican Central American South American Other
Alcohol Users Only
N=293
Mean
SD
N=211
Mean
SD
n=100 n=35 n=36 n=8 n=24 n=65 n=25
2.99 3.34 1.86 2.63 2.21 2.22 2.24
2.65 3.31 2.30 2.72 2.17 2.08 2.00
n=78 n=25 n=22 n=6 n=16 n=44 n=20
3.83 4.68 3.05 3.50 3.31 3.27 2.80
2.24 3.01 2.24 2.59 1.82 1.70 1.85
Note. Table only includes participants who provided data on both sub-ethnicity and AUDIT-C. There were no significant differences on alcohol use across H/L sub-ethnicities.
24 Table 2.
Tai Chi
Mantra Meditation
Yoga
Mindful Meditation
Spiritual Meditation
Informal Meditation
Percent of Engagement in Mindfulness-Related Practices by H/L Sub-ethnicity Mexican
Puerto Rican
Cuban
Dominican
Central American
Ns Never heard of Heard of it, never done it Did in past, not currently Currently do
110 12.7 21.8
39 2.6 23.1
41 19.5 12.2
10 0 30.0
27 11.1 11.1
14.5
17.9
9.8
20.0
45.5
56.4
58.5
Never heard of Heard of it, never done it Did in past, not currently Currently do
8.2 34.5
2.6 30.8
30.0
South American
Other
Entire Sample
78 12.8 24.4
27 22.2 29.6
332 12.6 21.1
7.4
15.4
14.8
13.8
40.0
55.6
39.7
33.3
47.5
12.2 46.3
20.0 50.0
3.7 29.6
9.0 37.2
7.4 40.7
7.9 37.0
25.6
29.3
10.0
14.8
25.6
29.6
26.1
23.6
41.0
12.2
10.0
40.7
21.8
22.2
25.2
Never heard of Heard of it, never done it Did in past, not currently Currently do
6.4 36.4
7.7 41.0
4.9 43.9
0 40.0
7.4 25.9
6.4 29.5
0 40.7
5.6 36.4
34.5
17.9
19.5
30.0
18.5
35.9
37.0
29.3
19.1
33.3
29.3
20.0
37.0
21.8
22.2
24.6
Never heard of Heard of it, never done it Did in past, not currently Currently do Never heard of Heard of it, never done it Did in past, not currently Currently do
0 39.1
5.1 51.3
2.4 43.9
0 40.0
3.7 29.6
3.8 28.2
0 37.0
2.1 38.1
40.9
33.3
34.1
50.0
40.7
52.6
44.4
41.9
16.4 21.8 60.0
4.0 25.6 48.7
19.5 14.6 53.7
0 30.0 50.0
14.8 11.1 59.3
9.0 28.2 50.0
18.5 25.9 63.0
14.1 22.6 55.7
10.0
12.8
22.0
0
7.4
10.3
11.1
11.1
4.5
12.8
9.8
10.0
11.1
5.1
0
6.7
Never heard of Heard of it, never done it Did in past, not currently Currently do
22.7 63.6
25.6 56.4
29.3 61.0
20.0 70.0
22.2 59.3
21.8 62.8
11.1 77.8
22.3 63.3
10.0
12.8
9.8
0
3.7
9.0
11.1
9.7
0
5.1
0
0
7.4
0
0
1.2
Note. Data reflect the within sub-ethnicity percentage (e.g., among Puerto Ricans, the percent who had never heard of yoga).
25 Table 3. Length of Engagement in Mindfulness-Related Practices
Less than 6 months 7 months – 2 years 3 – 5 years 6 – 10 years 11 or more years
Informal Mindfulness (n=159) 15.1% 25.2% 22.0% 16.4% 21.4%
Spiritual (n=83) 4.8% 10.8% 12.0% 6.0% 66.3%
Mindfulness Meditation (n=81) 23.5% 28.4% 25.9% 12.3% 9.9%
The Relationship of Mindfulness and Mindfulness-Related Practices with Alcohol Use among Hispanics/Latinx Christine Vinci , Lauren Malkhasyan , Vani N. Simmons , Virmarie Correa-Fernandez PII: DOI: Reference:
S0165-1781(19)31674-9 https://doi.org/10.1016/j.psychres.2020.112774 PSY 112774
To appear in:
Psychiatry Research
Received date: Revised date: Accepted date:
2 August 2019 3 December 2019 5 January 2020
Please cite this article as: Christine Vinci , Lauren Malkhasyan , Vani N. Simmons , Virmarie Correa-Fernandez , The Relationship of Mindfulness and Mindfulness-Related Practices with Alcohol Use among Hispanics/Latinx, Psychiatry Research (2020), doi: https://doi.org/10.1016/j.psychres.2020.112774
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1 Highlights No differences emerged among H/L sub-ethnicities on mindfulness-related practices. Spiritual practices were associated with less problematic alcohol use. Higher trait mindfulness was associated with less problematic alcohol use. Mindfulness appears protective regarding problematic alcohol use among H/L.
2 The Relationship of Mindfulness and Mindfulness-Related Practices with Alcohol Use among Hispanics/Latinx
Christine Vinci,1 Lauren Malkhasyan,1 Vani N. Simmons,1 & Virmarie Correa-Fernandez2
1
2
Moffitt Cancer Center Tampa, FL 33617
University of Houston Houston, TX 77004
Corresponding Author Christine Vinci, Ph.D. Moffitt Cancer Center Health Outcomes and Behavior 4115 E Fowler Ave. Tampa, FL 33617 Phone: 813-745-5421 Fax: 813-449-6871 Email: [email protected]
Declaration of Interest: None.
Abstract Hispanics/Latinx (H/Ls) are the largest ethnic minority group in the U.S., and three of the four leading causes of death are associated with problematic alcohol use. This study examined the relationship between mindfulness and alcohol use among H/Ls and whether differences emerged by sub-ethnicity. Participants (N=341; 49.7% female; average age=28.57) were H/Ls currently living in the U.S. Survey questions were answered online in English or Spanish. Participants
3 primarily endorsed engaging in informal mindfulness practices (47.5%), spiritual practices (25.2%), and mindfulness meditation (24.6%). No significant differences emerged among H/L sub-ethnicities. Spiritual practices and higher mindfulness were associated with less problematic alcohol use among the entire sample. Similar results were found among drinkers-only. Findings shed light on commonly used mindfulness practices and indicate that very few differences emerge among H/L sub-ethnicities on mindfulness practices and general mindfulness. The delivery/tailoring of mindfulness-based interventions (MBIs) may not need to differ amongst H/L sub-ethnicities in the U.S. Aspects of mindfulness appear protective regarding problematic alcohol use, suggesting that future MBIs that increase mindfulness should be explored for this population. Keywords: Hispanics/Latinx; mindfulness; alcohol use; intervention development; subethnicities
4 1. Introduction Hispanics/Latinx (H/Ls) currently comprise about 17% of the U.S. population, and this number is expected to grow to 30% by 2060 (U.S. Census Bureau, 2015; Colby & Ortman, 2015). Three of the four leading causes of death among H/Ls are associated with problematic alcohol use (e.g., cancer, heart disease, and stroke; Larsson et al., 2016; Nelson et al., 2013; Siegel et al., 2015; Whitman et al., 2017). H/Ls also have higher incident rates of liver disease, and often develop liver disease at a younger age and have a more severe presentation than nonH/Ls (Carrion et al., 2011; Levy et al., 2015). Some of these findings might be related to the notion that although H/Ls as a group are less likely to drink than non-H/Ls in the U.S., among those H/Ls who do drink alcohol, they do so at higher rates than non-H/Ls (CDC, 2014). Furthermore, H/Ls report lower substance use treatment utilization, including for alcohol use problems (Alvarez et al., 2007; Chartier & Caetano, 2010). Because heavy alcohol use among H/Ls can result in high rates of morbidity and mortality, interventions designed to decrease use would likely benefit this population. Mindfulness has been associated with decreased alcohol use (Bowen et al., 2006; Brewer et al., 2009; Wupperman et al., 2012; Zgierska et al., 2008) and has been defined as directed, flexible cognitive processing that allows an individual to observe thoughts and emotions, as opposed to reacting to them (Breslin et al., 2002). A central factor in this process is the ability to direct attention in a particular, purposeful way without judgment (Kabat-Zinn, 1994; Shapiro et al., 2006). Through mindfulness practices, individuals are taught to notice unpleasant experiences (e.g., thoughts, emotions), without immediately trying to get rid of or change them. Through these processes, individuals can alter automatic cognitive processes, and in turn increase cognitive flexibility (i.e., the experience is viewed from an outside, objective
5 perspective; Shapiro et al., 2006; Roemer & Orsillo, 2003; Teasdale et al., 1995; Teasdale et al., 2000; Williams et al., 2000). In other words, mindfulness can allow a person to shift out of automatic pilot and decrease reactivity, which can be especially helpful when trying to change a habitual behavior pattern. Mindfulness can be defined as a general trait that an individual has and demonstrates in their day-to-day life (Baer et al., 2006). For example, an individual high in trait mindfulness would naturally pay attention to a given activity (e.g., driving to work), notice the impact of their emotions on their body (e.g., shoulder tension), or even be aware of common patterns of their thoughts (e.g., “planning” thoughts; “worry” thoughts). In addition to measuring trait mindfulness, researchers can also collect data on mindfulness practices that someone engages in (e.g., mindful meditation; yoga). Mindfulness-based interventions (MBIs) consist of several mindfulness practices that an individual learns over the course of several weeks (e.g., Bowen et al., 2011). The existing theoretical and empirical literature on mindfulness suggests that specific mechanisms underlie MBIs for alcohol use, including increased attention/awareness, the ability to shift out of “autopilot”, and a general increased tolerance of unpleasant experiences (Garland et al., 2014; Karyadi et al., 2014; Witkiewitz et al., 2014). However, we know very little about the impacts of these interventions or mechanisms among H/Ls. In fact, to our knowledge it appears that no prior research has specifically examined a mindfulness-based intervention that addresses alcohol use for H/Ls. Thus, prior to implementing such interventions in this population, it is important to first assess current use of these practices among H/Ls and to explore whether practices might differ among sub-ethnicities (e.g., Mexican vs Cuban). Such information is vital to inform the development/modification of MBIs for a diverse group of H/Ls, specifically with regards to facilitating treatment utilization.
6 Prior studies have revealed frequent use of Complementary and Alternative Medicine (CAM; e.g., herbs, spiritual healing) for health concerns among H/L populations due to unique cultural practices and H/Ls general approach to formal healthcare (Ortiz et al., 2007; Garces et al., 2006). Although mindfulness-based approaches are a category that often falls under CAM, very little research has been conducted on the use of various mindfulness-related practices among H/Ls. For instance, although we know that when compared to non-H/Ls in the U.S. H/Ls report engaging in fewer mindfulness-based activities (e.g., yoga, tai chi; Olano et al., 2015), we do not have in-depth understanding about engagement in mindfulness practices (e.g., length of time, reasons for practice), how these practices relate to health behaviors such as alcohol use, and how these may (or may not) differ by sub-ethnicity (e.g., Mexican vs. Cuban vs. Puerto Rican). Although H/Ls tend to be viewed as a homogenous group, differences have arisen in terms of prevalence of certain health behaviors, including alcohol use (Caetano et al., 2009). For instance, US-born Puerto Ricans and Mexicans have higher rates of alcohol dependence than Cubans (Caetano et al., 2009). Thus, it is important to consider specific sub-ethnicities within the context of intervention development. It is also unclear how trait mindfulness (one’s general level of mindfulness in day-to-day life) is related to problematic alcohol use among H/Ls. It would be expected that higher trait mindfulness would be associated with lower problematic alcohol use, as is typically found in other populations (Karyadi et al., 2014; Vinci et al., 2016b). This paper attempts to answer these questions in an effort to inform treatment development for H/Ls. To better understand mindfulness and alcohol use among H/Ls, we first present data on the current use of mindfulness-related practices and overall levels of trait mindfulness and problematic alcohol use, followed by how these may differ among sub-ethnicities. Second, we hypothesized that higher trait mindfulness would be associated with less problematic alcohol use.
7 2. Method 2.1 Participants Participants in this study met the following eligibility criteria: 18 years of age or older, self-identified as Hispanic/Latinx, were able to speak and read in either English or Spanish, currently lived in the U.S., and were able to provide informed consent. 2.2 Procedure The online survey was available from October 2017 to April 2018. All participants were recruited through advertisements in both English and Spanish presented on various social media platforms (e.g., Facebook, Craigslist and Reddit). Study ads included a survey link that brought participants to the informed consent page. Following completing informed consent, participants answered the inclusion criteria questions, and if eligible, began the survey that took about 15 minutes to complete. Participants who completed the survey had the option to provide their email address to be entered into a drawing for the chance to win a $100 gift card. All procedures were approved by the institution’s IRB. 2.3 Measures The entire survey, including study advertisements, informed consent, and questionnaires, was available in either English or Spanish. These documents were translated from English to Spanish in an iterative process. They were first translated from English to Spanish by a certified translator, and then checked by two native speakers. Feedback from the native speakers was then discussed with the translator, and final edits were made. The following measures were analyzed as part of the current study. 2.3.1 Demographics. Demographic information was collected from all participants, and included information related to gender, age, sexual orientation, marital status, education, and
8 household income. Participants were also asked, “Culturally, which group do you most identify with?” Response choices included: Mexican, Puerto Rican, Cuban, Dominican, Central American, South American, and Other. 2.3.2 Alcohol Use Disorders Identification Test-Concise (AUDIT-C). Participants answered questions regarding their alcohol use on the AUDIT-C, which assessed quantity, frequency and binge drinking. Interpretation of scores vary by gender, and include a score of > 3 being considered problematic alcohol use for women, and a score of > 4 being considered problematic alcohol use for men (Bush et al., 1998; Bradley et al., 2003). The AUDIT-C is considered an effective measure of alcohol use among Latinx individuals (Frank et al., 2008). Cronbach’s alpha for the AUDIT-C in current study was .71. 2.3.3 Mindful Attention Awareness Scale (MAAS). The MAAS is a 15-item questionnaire that measures the attentional component of mindfulness (Brown & Ryan, 2003). Participants responded on a 6-point Likert scale ranging from 1 (almost always) to 6 (almost never), with higher scores being indicative of greater levels of trait mindfulness. The MAAS has demonstrated reliability and validity in a bilingual English-Spanish population (Johnson et al., 2014). Cronbach’s alpha for the MAAS in current study was .88. 2.3.4 Five Facet Mindfulness Questionnaire (FFMQ). The non-judging subscale of the FFMQ was used to assess the ability of participants to approach emotions and thoughts with a sense of nonjudgment/acceptance (Baer et al., 2006). This nonjudging subscale consisted of 8 items rated on a Likert scale from 1 (never or very rarely true) to 5 (very often or always true). Items are reversed scored on this subscale, such that higher scores result in higher mindfulness. We chose to include only this subscale of the FFMQ to reduce participant burden. Further, given the MAAS primarily targets the attentional component of mindfulness, the FFMQ nonjudging
9 subscale provides additional information on mindfulness not captured in that measure. The FFMQ has been shown to effectively measure mindfulness in Spanish samples (Cebolla et al., 2012). Cronbach’s alpha for the FFMQ-nonjudging subscale in the current study was .93. 2.3.5 Mindfulness-Related Practice. Participants were asked to identify their familiarity with various mindfulness-related practices. We use the term “mindfulness-related practices”, as it is possible that although an individual might endorse a certain practice, we do not know whether they engage in it mindfulness based on the survey results. They were asked: “Below is a list of categories of practices that you may or may not have done in your life. Please check what practices you’ve done: a) tai chi/qui gong, b) yoga, c) mindfulness meditation (for example, formal seated or walking practice with a primary focus on breathing; Vipassana; MindfulnessBased Stress Reduction), d) mantra meditation (for example, transcendental meditation), e) devotional/spiritual meditation (for example, prayer), and f) informal mindfulness practice (for example, trying to focus your attention only on a certain activities, such as eating, driving, washing the dishes, etc.).” Of those choices, if a participant did endorse current practice, they were then asked to identify how often they engaged in each practice from the following options: a) less than 6 months, b) 7 months – 2 years, c) 3 – 5 years, d) 6 – 10 years, or e) 11 or more years. Participants were then asked to indicate their primary reason for currently engaging in the practices they checked off: a) to help manage stress, b) to change some behavior (for example, to lose weight, quit smoking, etc.), c) because they enjoyed it, or d) because it was related to their religious/spiritual beliefs. They were able to select as many options as applicable. 2.4 Analytic Plan
10 Descriptive analyses are presented to describe the demographics, alcohol use, mindfulnessrelated practices, and trait mindfulness of the sample. Analysis of Variance (ANOVA) was used when examining sub-ethnic group differences on mindfulness practices and trait mindfulness. Hierarchical linear regressions were implemented for the mindfulness and alcohol use analyses; relevant covariates (described below) were included in these models. 3. Results 3.1 Sample Characteristics Participants (N = 341) were 49.7% female with an average age of 28.57 (SD = 11.49). About 12% chose to complete the survey in Spanish. Participants who completed the survey in Spanish had significantly higher MAAS scores than those who completed the survey in English; therefore this variable was controlled for in all subsequent analyses. There were no significant group differences on the FFMQ or AUDIT-C, based on the language the survey was completed in. When asked “Culturally, which group do you most identify with?” participants reported: Mexican (32.3%), South American (22.9%), Cuban (12%), Puerto Rican (11.4%), Central American (7.9%), Dominican (2.9%), Other (7.9%), and choose not to answer (2.6%). The majority of the sample indicated their race as White (73%), followed by more than one race (7%), and Other (7.6%). The sample was 19.4% LGBQ (Lesbian, Gay, Bisexual, Queer) and 33.4% were married or living with a partner. Regarding education and income, 96.8% reported having a high school diploma or greater (24.3% of the sample reported having an undergraduate degree) and 41.6% reported less than a $30,000 annual household income. Average scores were as follows for the MAAS: 3.68 (SD = .95) and FFMQ: 3.07 (SD = 1.09). On the AUDIT-C, the entire sample reported an average score of 2.58 (SD = 2.52). When excluding those who endorsed never drinking (thus only including alcohol drinkers, n = 211), the
11 average score was 3.59 (SD = 2.29). Female drinkers had an average of 3.11 (SD = 1.95) and male drinkers 3.97 (SD = 2.45). Table 1 presents AUDIT-C scores by sub-ethnicity. H/L subethnicities did not significantly differ on the AUDIT-C (both when examining the entire sample and for alcohol drinkers-only). We re-ran this analysis including only those groups with larger sample sizes (i.e., Mexican, Puerto Rican, Cuban, South American), and results were the same. 3.2 Mindfulness-related Practice Among mindfulness-related practices, participants endorsed currently engaging in informal mindfulness practices (47.5%), spiritual practices (25.2%), mindfulness meditation (24.6%), yoga (14.1%), mantra meditation (6.7%), and tai chi (1.2%). Results of an ANOVA indicated that there were no significant differences among H/L sub-ethnicities on mindfulness practices or general level of trait mindfulness on the MAAS or FFMQ. See Table 2 for a breakdown of mindfulness practices by sub-ethnicity. Among the subset of participants who endorsed current mindfulness-related practices, we further examined those who endorsed informal (n = 159), spiritual (n = 83), and mindfulness meditation (n = 81), given these were the practices most commonly reported. Regarding informal mindfulness practice and mindfulness meditation, most participants had been practicing for 7 months – 2 years. For spiritual practices, most reported practicing for 11 or more years. Table 3 presents a more detailed breakdown of the frequency of these practices. Regarding why participants currently engaged in any mindfulness-related practice, they reported the following (could select more than one): to manage stress (50.1%), for enjoyment (38.7%), to change some behavior (25.8%), for religious/spiritual purposes (23.8%), and other (4.4%). 3.3 Mindfulness and Alcohol Use
12 Each mindfulness-related practice (dichotomized as never/do not currently practice vs. currently practice) was individually examined as a predictor of alcohol use with hierarchical linear regression. Gender and education were added as covariates in each model, as significant differences emerged between groups on the outcome variable of AUDIT-C score. As mentioned above, language the survey was completed in was also included as a covariate. Results indicated that only spiritual practices were associated with less problematic alcohol use, F(4,293) = 5.11, p = .001 (spiritual practices: B = -.70, t = -2.19, p = .029). No other mindfulness-related practice was significantly associated with alcohol use. Higher trait mindfulness (according to the MAAS) was also associated with less problematic alcohol use, F(4,293) = 6.79, p = .001 (MAAS: B = .50, t = -3.28, p = .001). The FFMQ model was not significant. These same analyses were conducted after selecting only those participants who endorsed drinking alcohol, thus excluding never drinkers. Results indicated that no specific mindfulnessrelated practices were associated with alcohol use. Regarding trait mindfulness, higher mindfulness was associated with less problematic alcohol use according to the MAAS, F(4,209) = 6.03, p = .001 (MAAS: B = -.47, t = -2.80, p = .006). The FFMQ model was not significant. 4. Discussion This paper presents some of the first data on mindfulness-related practices and alcohol use among H/L sub-ethnicities. Findings indicated that informal mindfulness practices were the most frequently endorsed, with tai chi being the least. We did not find significant differences in mindfulness practices by sub-ethnicity, although variability did exist (e.g., for yoga, there was a range from 0% for Dominican and 19.5% for Cuban). Of participants who reported currently engaging in mindfulness-related practices, most reported using them to manage stress, followed by for enjoyment. Among the entire sample, engagement in spiritual practices and high trait
13 mindfulness was associated with less problematic alcohol use. Among alcohol users only, high trait mindfulness was also associated with less problematic alcohol use. These results have direct implications for intervention development among H/Ls. To our knowledge, no prior studies have presented a detailed description of mindfulnessrelated practices among H/L sub-ethnicities. Our results suggest that a range of practices are utilized by this population, with informal meditation, spiritual practices, and mindfulness meditation being the most common. Such findings suggest that when considering what practices to incorporate into MBIs, H/L sub-ethnic groups have similar experiences with mindfulness practices and therefore it may not be necessary to tailor practices to certain sub-ethnicities. Further, informal mindfulness and mindfulness meditations are central to most MBIs (Bowen et al., 2011; Kabat-Zinn, 1990; Kuyken et al., 2008; Teasdale et al., 2000), potentially making the adaptation of existing MBIs acceptable for this population. Researchers developing MBIs may also consider how to support existing spiritual practices through mindfulness practices. Previous research has shown that a sample of predominately African American participants reported that mindfulness practices could supplement their religion and spirituality (Spears et al., 2017). These data should be interpreted all while keeping in mind that we only assessed experience with mindfulness practices, not preference. Future research on intervention development should consider preferences for certain mindfulness practices among H/Ls. Regarding alcohol use, it appears that engagement in spiritual practices serve as a protective factor, which is consistent with extant literature (Kendler et al., 2003; Leigh et al., 2005; Witkiewitz et al., 2016). Our study did not inquire about what spiritual practices were utilized. Extant literature has shown that different spiritual practices (e.g., high thankfulness and viewing God as a judge) are associated with lower alcohol dependence (Kendler et al., 2003);
14 thus, future research among H/Ls could further assess specific spiritual practices to inform treatment development. In both the entire sample and among alcohol users only, high trait mindfulness (according to the MAAS) was associated with less problematic alcohol use. To our knowledge, this is the first analysis to examine the role of trait mindfulness and alcohol use among a large sample of H/Ls. This finding in particular has implications for intervention development, as MBIs often aim to increase trait mindfulness to impact psychosocial outcomes. Given we specifically examined alcohol use in the current study, future research should examine whether a MBI targeting alcohol use among H/Ls might be useful in increasing trait mindfulness, thus impacting problematic drinking. Future research in this area is further supported by participants’ responses stating that the main reason why they currently engage in mindfulness practices is to manage stress. Given H/Ls have lower substance use treatment utilization than other racial/ethnic groups (Alvarez et al., 2007; Chartier et al., 2010), it is important to consider specific aspects of treatment that might be already practiced among H/Ls and incorporate them into alcohol use treatment programs. The nonjudging facet of the FFMQ was not associated with problematic drinking. Previous research in non-H/L populations have found mixed results regarding nonjudging and alcohol use (Bodenlos et al., 2015; Fernandez et al., 2014; Murphy & MacKillop, 2012; Roos et al., 2016; Vinci et al., 2016a), with many studies finding no significant association (Bodenlos et al., 2015; Fernadez et al., 2014; Roos et al., 2016). Possible explanations may include the use of the FFMQ nonjudging subscale itself, or, that the assessment of alcohol use was limited (e.g., the AUDIT-C captures problematic use, not negative consequences related to use). Future research
15 should attempt to replicate these results among H/L, and also consider the utilization of other assessments of nonjudging and alcohol-related variables. Limitations of this study should be noted. First, we do not know how participants selfdefined each mindfulness-related practice. Although the answer choices included examples, it is not entirely clear how “spiritual practices” was interpreted, for instance. Participants could even engage in these practices in ways that are inconsistent with mindfulness. We also only examined the presence/absence of specific practices, and not the frequency/quantity of each practice. As such, it is possible that frequency and/or duration are related to alcohol use; future research should ask these additional questions about mindfulness practices in order to fully understand these relationships. Second, we utilized the MAAS and the FFMQ subscale of nonjudging to capture trait mindfulness, and therefore, future research is needed to examine how these other aspects of mindfulness (e.g., nonreactivity, compassion) were not collected. Thus, future research is needed to examine whether or how these other components of mindfulness relate to alcohol use among Latinx individuals. Third, characteristics of this sample (e.g., younger age) may limit the generalizability of findings to other H/Ls in the U.S. Third, for some subethnicities (e.g., Dominican), we had low sample sizes. Thus, it is possible that if group differences do exist, we were not able to capture them. For example, we did not find that alcohol use differed by sub-ethnicity, which has been reported previously (Caetano et al., 2009). However, even when limiting the analysis to those groups with larger sample sizes, group differences did not exist on this outcome. Investigators who are interested in developing MBIs for a particular sub-ethnicity that had a low sample size in the current study may want to conduct a separate study targeting that specific group in order to obtain an adequate number of participants. Despite these limitations, this study is one of the first to present an analysis of
16 mindfulness-related practices and alcohol use among specific H/Ls sub-ethnicities. Furthermore, the sample consisted of a large number of H/Ls, with both males and females equally represented, from across the U.S. In sum, these data present an overview of the mindfulness-related practices engaged in by H/Ls in the U.S. Importantly, spiritual practices and trait mindfulness were associated with less problematic alcohol use. Such information has the potential to inform interventions for problematic health behaviors (e.g., alcohol use) among H/Ls. Future research is needed to examine preferences for mindfulness-based practices among those with varying levels of familiarity with mindfulness in order to develop/modify MBIs for this population.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author Statement CV was responsible for the conceptualization of the manuscript, oversaw data collection and analysis, and wrote the first draft of the paper. LM assisted in data collection and the writing and editing of the manuscript. VS assisted in designing the study and in writing and editing the manuscript. VC assisted in designing the study and in writing and editing the manuscript. Declaration of Interest Declarations of interest: none.
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23 Table 1. Alcohol Use by Sub-ethnicity Entire Sample
Mexican Puerto Rican Cuban Dominican Central American South American Other
Alcohol Users Only
N=293
Mean
SD
N=211
Mean
SD
n=100 n=35 n=36 n=8 n=24 n=65 n=25
2.99 3.34 1.86 2.63 2.21 2.22 2.24
2.65 3.31 2.30 2.72 2.17 2.08 2.00
n=78 n=25 n=22 n=6 n=16 n=44 n=20
3.83 4.68 3.05 3.50 3.31 3.27 2.80
2.24 3.01 2.24 2.59 1.82 1.70 1.85
Note. Table only includes participants who provided data on both sub-ethnicity and AUDIT-C. There were no significant differences on alcohol use across H/L sub-ethnicities.
24 Table 2.
Tai Chi
Mantra Meditation
Yoga
Mindful Meditation
Spiritual Meditation
Informal Meditation
Percent of Engagement in Mindfulness-Related Practices by H/L Sub-ethnicity Mexican
Puerto Rican
Cuban
Dominican
Central American
Ns Never heard of Heard of it, never done it Did in past, not currently Currently do
110 12.7 21.8
39 2.6 23.1
41 19.5 12.2
10 0 30.0
27 11.1 11.1
14.5
17.9
9.8
20.0
45.5
56.4
58.5
Never heard of Heard of it, never done it Did in past, not currently Currently do
8.2 34.5
2.6 30.8
30.0
South American
Other
Entire Sample
78 12.8 24.4
27 22.2 29.6
332 12.6 21.1
7.4
15.4
14.8
13.8
40.0
55.6
39.7
33.3
47.5
12.2 46.3
20.0 50.0
3.7 29.6
9.0 37.2
7.4 40.7
7.9 37.0
25.6
29.3
10.0
14.8
25.6
29.6
26.1
23.6
41.0
12.2
10.0
40.7
21.8
22.2
25.2
Never heard of Heard of it, never done it Did in past, not currently Currently do
6.4 36.4
7.7 41.0
4.9 43.9
0 40.0
7.4 25.9
6.4 29.5
0 40.7
5.6 36.4
34.5
17.9
19.5
30.0
18.5
35.9
37.0
29.3
19.1
33.3
29.3
20.0
37.0
21.8
22.2
24.6
Never heard of Heard of it, never done it Did in past, not currently Currently do Never heard of Heard of it, never done it Did in past, not currently Currently do
0 39.1
5.1 51.3
2.4 43.9
0 40.0
3.7 29.6
3.8 28.2
0 37.0
2.1 38.1
40.9
33.3
34.1
50.0
40.7
52.6
44.4
41.9
16.4 21.8 60.0
4.0 25.6 48.7
19.5 14.6 53.7
0 30.0 50.0
14.8 11.1 59.3
9.0 28.2 50.0
18.5 25.9 63.0
14.1 22.6 55.7
10.0
12.8
22.0
0
7.4
10.3
11.1
11.1
4.5
12.8
9.8
10.0
11.1
5.1
0
6.7
Never heard of Heard of it, never done it Did in past, not currently Currently do
22.7 63.6
25.6 56.4
29.3 61.0
20.0 70.0
22.2 59.3
21.8 62.8
11.1 77.8
22.3 63.3
10.0
12.8
9.8
0
3.7
9.0
11.1
9.7
0
5.1
0
0
7.4
0
0
1.2
Note. Data reflect the within sub-ethnicity percentage (e.g., among Puerto Ricans, the percent who had never heard of yoga).
25 Table 3. Length of Engagement in Mindfulness-Related Practices
Less than 6 months 7 months – 2 years 3 – 5 years 6 – 10 years 11 or more years
Informal Mindfulness (n=159) 15.1% 25.2% 22.0% 16.4% 21.4%
Spiritual (n=83) 4.8% 10.8% 12.0% 6.0% 66.3%
Mindfulness Meditation (n=81) 23.5% 28.4% 25.9% 12.3% 9.9%