Qual Life Res (2013) 22:2639–2659

DOI 10.1007/s11136-013-0395-8

Mindfulness: a systematic review of instruments to measure

an emergent patient-reported outcome (PRO)
Taehwan Park • Maryanne Reilly-Spong •

Cynthia R. Gross

Accepted: 11 March 2013 / Published online: 29 March 2013

 Springer Science+Business Media Dordrecht 2013

Abstract consistency and construct validation by hypothesis testing.

Purpose Mindfulness has emerged as an important health However, none of the instruments had sufficient evidence
concept based on evidence that mindfulness interventions of content validity. Comprehensiveness of construct cov-
reduce symptoms and improve health-related quality of erage had not been assessed; qualitative methods to con-
life. The objectives of this study were to systematically firm understanding and relevance were absent. In addition,
assess and compare the properties of instruments to mea- estimates of test–retest reliability, responsiveness, or
sure self-reported mindfulness. measurement error to guide users in protocol development
Methods Ovid Medline, CINAHL, and PsycINFO or interpretation of scores were lacking.
were searched through May 2012, and articles were Conclusions Current mindfulness scales have important
selected if their primary purpose was development or conceptual differences, and none can be strongly recom-
evaluation of the measurement properties (validity, reli- mended based solely on superior psychometric properties.
ability, responsiveness) of a self-report mindfulness scale. Important limitations in the field are the absence of qual-
Two reviewers independently evaluated the methodologi- itative evaluations and accepted external referents to sup-
cal quality of the selected studies using the COnsensus- port construct validity. Investigators need to proceed
based Standards for the selection of health status cautiously before optimizing any mindfulness intervention
Measurement INstruments checklist. Discrepancies were based on the existing scales.
discussed with a third reviewer and scored by consensus.
Finally, a level of evidence approach was used to synthe- Keywords Mindfulness
Instruments
Psychometrics

size the results and study quality. Measurement properties
COSMIN checklist

Results Our search strategy identified a total of 2,588 Systematic review
articles. Forty-six articles, reporting 79 unique studies, met
inclusion criteria. Ten instruments quantifying mindfulness
as a unidimensional scale (n = 5) or as a set of 2–5 sub- Introduction
scales (n = 5) were reviewed. The Mindful Attention
Awareness Scale was evaluated by the most studies Mindfulness has emerged as an important concept in health
(n = 27) and had positive overall quality ratings for most and outcomes research, driven by a rapidly growing body
of the psychometric properties reviewed. The Five Facet of evidence that mindfulness training reduces symptoms
Mindfulness Questionnaire received the highest possible and improves quality of life. Mindfulness training is the
rating (‘‘consistent findings in multiple studies of good basis for widely accepted interventions in psychosomatic
methodological quality’’) for two properties, internal medicine and psychology [1]. Recent reviews have sum-
marized the evidence of the efficacy of these mindfulness
interventions for persons with cancer [2], chronic medical
T. Park
M. Reilly-Spong
C. R. Gross (&)
conditions [3], and psychological disorders [4]. Clinical
College of Pharmacy, University of Minnesota, Minneapolis,
MN, USA efficacy and durability have been shown for depression
e-mail: gross002@umn.edu relapse prevention, anxiety reduction, and insomnia [4–7].

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Recent meta-analyses estimated small- to medium-sized personal factors highly salient to health maintenance and
treatment effects for the impact of mindfulness training on disease prevention which are not conventionally considered
symptoms of stress, anxiety, and depression [4, 7, 8]. outcomes, such as self-efficacy, self-esteem, and perceived
Clinical trials of mindfulness training with health providers social support, have been included in popular frameworks for
and community samples demonstrate significant improve- PROs, and self-report instruments to measure these health-
ments in stress management and enhanced well-being [9, related factors have been developed using PRO guidelines
10]. Mindfulness training has also been shown to improve (http://www.nihpromis.org/).
the biomarkers of glycemic control in diabetes [11, 12], Numerous studies have evaluated self-report instruments
enhance immune response [13], and accelerate skin healing to quantify mindfulness [23–25]; however, a comprehen-
in psoriasis [14]. sive, systematic review of these instruments has not been
Mindfulness can be a dynamically changing state, a trait conducted using a level of evidence approach. The level of
that differs between persons, and a skill that can be evidence approach relies upon systematically ranking
enhanced through training [15]. Drawing upon sources in studies by the rigor of their methods so that final recom-
Buddhist psychology, mindfulness has been described as mendations reflect results from the most methodologically
arising from the intentional deployment of a triad of sound studies. Conclusions from a level of evidence
intertwined ‘‘behaviors of the mind’’—attention, aware- approach consider both the consistency of findings across
ness, and attachment—and defined as ‘‘the active maxi- studies and the rigor of those studies. The strongest evi-
mizing of the breadth and clarity of awareness’’ [16]. dence derives from consistent findings from multiple
Adapting mindfulness for use in health interventions for studies judged to have good or excellent methods. The aim
patients with cancer, Susan Bauer-Wu explains mindful- of this study is to critically appraise and summarize the
ness as ‘‘Our capacity to intentionally bring awareness to quality of the measurement properties of all published self-
present-moment experience with an attitude of openness report mindfulness instruments using a level of evidence
and curiosity. It is being awake to the fullness of our lives approach and the COnsensus-based Standards for the
right now, through engaging the five senses and noticing selection of health Measurement INstruments (COSMIN)
the changing landscapes of our minds without holding on guidelines [26]. COSMIN uses taxonomy of measurement
to or pushing away from any of it’’ [17]. In preparing this properties selected for relevance to health-related PROs
review, we were guided by the two-part model of mind- based on the consensus of an international team of experts
fulness proposed by Bishop and colleagues following a in health outcomes research. COSMIN includes uniform
series of discussions among an interdisciplinary group of definitions and standards for the evaluation of methodo-
researchers [18]. This consensus model of mindfulness logical quality of studies to be reviewed and has been used
encompasses two components, attention and acceptance. in more than a dozen systematic reviews published in peer-
The attention component pertains to maintaining awareness reviewed journals.
of present moment experience, and the acceptance com-
ponent relates to the quality of relationship to experience
(e.g., attitudes of openness and curiosity). This two-part Methods
conceptualization of mindfulness has been widely cited,
and attention and acceptance are common elements across Search strategy
most definitions used in the construction of self-reports
[19]. The electronic databases Ovid Medline (1949 through
Although the mechanisms responsible for the health May 2012), CINAHL (1981 through May 2012), and
benefits of mindfulness are not known, clinical, experi- PsycINFO (1806 through May 2012) were searched using
mental, and brain imaging studies suggest increased symp- mindfulness index terms in combination with psychometric
tom awareness, reduced emotional arousal, and greater terms as described in ‘‘Appendix 1.’’ A manual search of
engagement in health-promoting behaviors are involved [20, the references of the included studies was conducted to
21]. Measuring mindfulness is important for research aimed supplement the electronic search. The search was limited to
at understanding its role in helping people to deal with articles published in the English language.
emotional and physical health problems and to guide
refinements of mindfulness interventions to optimize health Selection criteria
benefits [22, 23]. It is appropriate to evaluate the measures of
mindfulness using a framework designed for patient-repor- Articles were selected if their primary purpose was to
ted outcomes (PROs), as large numbers of patients are being develop or evaluate the measurement properties of an
asked to complete mindfulness self-assessments in the con- original version of a mindfulness instrument. The instru-
text of health care and outcomes research [2, 3, 8]. Other ment had to quantify mindfulness and be developed for

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self-administration by adults. Instruments that were pro- construct it purports to measure. COSMIN groups three
gram-specific were excluded as were instruments that did properties in the validity domain: content validity, con-
not measure mindfulness per se. Therefore, instruments to struct validity, and criterion validity. Content validity
measure mindful eating [27], mindful coping [28], medi- includes face validity, comprehensiveness, and relevance
tation experience [29], mindfulness practice [30], of the items in an instrument for its target population and
self-compassion [31], and mindfulness-based relapse pre- purpose. Structural validity, hypothesis testing, and cross-
vention adherence and competence (MBRP-AC) [32] were cultural validity are aspects of construct validity. Structural
excluded. Articles were excluded if they were not full-text, validity is the evidence to support the dimensionality of an
original articles (e.g., reviews, commentaries, or disserta- instrument, and hypothesis testing is the degree to which
tions) or if they were designed to create a brief, translated, relationships between an instrument and other measures
or adolescent/child’s version of another mindfulness scale. conform to expectations, including differences between
Articles about mindfulness instruments originally devel- known groups. Relationships are often assessed by the
oped in any language other than English were initially Pearson correlation coefficient (r). Criterion validity, the
excluded; however, after the review of the collected arti- extent that an instrument correlates with an accepted ‘‘gold
cles, an exception to this rule was made to include the standard,’’ was not applicable for this review, because there
Freiburg Mindfulness Inventory because of its importance is no gold standard for mindfulness. Cross-cultural validity,
to the field as the first insight meditation-inspired self- the extent that items of a translated or adapted version of an
report measure of mindfulness. Articles were also excluded instrument perform as items on the original perform, was
if the primary aim was to test the efficacy of a mindfulness also not evaluated for this review. The final domain is
intervention. The decision to exclude efficacy trials was responsiveness, the ability of an instrument to detect
based on the recommendation for the conduct of systematic change in the underlying construct. To assess responsive-
reviews from the text by De Vet et al. [33]. These authors ness, investigators pose hypotheses about expected corre-
note that efficacy studies generally provide only indirect lations between the change score on the target instrument
evidence on the measurement properties of an instrument, and change scores on other instruments for the same or
and this evidence is often difficult to interpret. Efficacy other constructs. This is essentially validity in a longitu-
trials have been the focus of a growing number of meta- dinal context. Responsiveness is not assessed by treatment
analyses. effect size in COSMIN. This approach is consistent with
One reviewer (T.P.) conducted the initial screening of the approach of Brown and Ryan [15], who noted that ‘‘the
titles and abstracts for all articles retrieved by the literature present study was not designed to test the efficacy of the
search and identified candidate articles. Two reviewers intervention per se, but rather to examine whether mind-
(T.P. and C.R.G.) assessed the full text of the candidate fulness and changes in it were related to well-being out-
articles and jointly made decisions regarding article comes and changes in them.’’
inclusion.

The COSMIN checklist and study quality assessment

Measurement properties
An evidence-based approach requires that results be relied
The COSMIN taxonomy groups psychometric properties upon only when they are produced by methodologically
into three domains: reliability, validity, and responsiveness sound studies. The COSMIN checklist contains 98 items to
[34]. Reliability, the degree to which an instrument is free assess whether a study of measurement properties meets
from measurement error, includes three properties: internal quality standards [36]. Study quality is determined sepa-
consistency, measurement error, and reliability. Internal rately for each measurement property, using 5–18 items
consistency is the degree of the interrelatedness among the each rated as poor, fair, good, or excellent. The final
items in an instrument and is typically assessed by Cron- quality rating for a property is the lowest rating of any item
bach’s alpha. Measurement error is the systematic and pertinent to that property (worst rating counts) [36].
random error that is not attributed to true changes in the Two reviewers (T.P. and C.R.G.) independently
underlying construct, and it is adequate if the smallest extracted data from the selected articles and evaluated
detectable change (SDC) on the instrument is less than the methodological quality using the COSMIN checklist as a
minimal important change (MIC) [35]. Reliability is the guide. Discrepancies were discussed with a third reviewer
proportion of the total variance reflecting true differences (M.R.-S.) to reach consensus. Where a single article pre-
between persons, assessed by intraclass correlation coeffi- sented multiple studies, each study was separately evalu-
cients (ICCs), Cohen’s Kappa, or test–retest correlations. ated and rated for every measurement property it
Validity is the extent to which an instrument measures the addressed.

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Best evidence synthesis instrument focused on the absence of attention to and

awareness of present experience and was designed to op-
Study findings were rated as ‘‘positive,’’ ‘‘negative,’’ or erationalize mindfulness as a single construct. This
‘‘indeterminate’’ for each measurement property based on instrument was intended to be generic and applicable to
criteria proposed by Terwee et al. (Table 1) [37]. Sum- persons regardless of experience with meditation. Sample
maries for each instrument were prepared showing how items are shown in Table 4. Most studies confirmed a one-
many studies of excellent, good, fair, or poor quality pro- factor structure for the MAAS [15, 39–42]. One study
vided positive, negative, or indeterminate results by prop- found that some items in the MAAS did not function well
erty. Overall ratings were then synthesized for each as indicators for a single latent construct [43]. There was
instrument across studies using a level of evidence support for the internal consistency of the MAAS (Cron-
approach that considered the number and methodological bach’s alphas ranging from 0.78 to 0.92) and evidence of
quality of the studies, and the consistency of their findings test–retest reliability (ICC = 0.81). Correlations between
(Table 2) [38]. Findings from poor-quality studies received the MAAS and other mindfulness instruments, such as the
no weight in the final synthesis. FMI, CAMS-R, SMQ, KIMS, and MMS, were weak to
moderate (r’s = 0.14–0.51) [15, 44, 45]. Consistent with
expectations for construct validity, MAAS scores were
Results positively correlated with measures of openness, internal
state awareness, positive and pleasant affect, and well-
The study selection process is presented in Fig. 1. A total being, and negatively correlated with neuroticism, anxiety,
of 2,588 unique articles were identified using the search stress, and rumination [15, 39, 44–47]. MAAS scores were
strategy; of these, 146 articles were selected based on their higher for meditators compared to non-meditators [43], but
title and abstract. For further assessment, the full text of there was no significant difference between novice medi-
these articles was examined resulting in the exclusion of 67 tators and non-meditators [40]. Several studies [15, 48, 49]
articles. As shown in Fig. 1, most of these were excluded have compared the MAAS to results on performance-based
because evaluation of psychometric properties was not the tasks (e.g., cognitive tests of attention, inhibition) with
primary focus of the article. Another 33 articles were then mixed results.
excluded because they addressed a translated, short or
modified version of the original instruments, leaving a total Kentucky Inventory of Mindfulness Skills (KIMS)
of 46 articles for inclusion in our review. These 46 articles
contained 79 separate studies and evaluated 10 different The KIMS was designed to assess the tendency to be
mindfulness instruments. Several studies evaluated multi- mindful in daily life in areas corresponding to the skills
ple instruments. Table 3 shows the characteristics of the taught in mindfulness interventions, particularly Dialectical
included studies, Table 4 presents the characteristics of the Behavior Therapy [50]. The KIMS consists of 39 items
included instruments, and Table 5 shows the COSMIN grouped into four subscales: Observe, Describe, Act with
ratings of the methodological quality of these studies, by Awareness, and Accept without Judgment. The Observe
measurement property. No selected article was completely subscale reflects the skill of observing or paying attention
excluded for poor methodological quality. Our synthesis of to internal (bodily sensations, thoughts, and emotions) and
the results and level of evidence for the properties of each external phenomena. The Describe subscale refers to a
mindfulness instrument is presented in Table 6. Results for tendency or ability to put sensations, perceptions, thoughts,
each instrument are summarized below. In these summa- feelings, emotions, or experiences into words. The Act with
ries, we use the following conventions for describing cor- Awareness subscale reflects the ability to focus undivided
relations: Correlations are considered strong if |r| is attention on the present. The Accept without Judgment
between 0.7 and 1.0, moderate if 0.4 B |r| \ 0.7, and weak subscale includes both the act of making judgments and
if 0 \ |r| \ 0.4. Results from studies of poor methodo- common examples of self-criticism. The 4-factor structure
logical quality are not included in these summaries. of the KIMS was supported by exploratory factor analysis
(EFA); 43 % of the variance was accounted for by
Mindfulness Attention Awareness Scale (MAAS) the 4-factors [50]. Although nearly adequate fit was shown
in confirmatory factor analysis (CFA), the analyses used a
The MAAS was the first widely disseminated measure of somewhat controversial ‘‘parceling approach’’ to overcome
mindfulness. It was designed to measure mindfulness as CFA sample size limitations, and others were unable to
present-centered attention-awareness in everyday experi- replicate the 4-factor solution by EFA [41]. The KIMS
ence, a state which varies within and between persons, and (global and subscales) had evidence of internal consistency
an attribute that may be cultivated with practice [15]. This (Cronbach’s alphas ranging from 0.72 to 0.97), and

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Table 1 Quality criteria for measurement properties adapted from Terwee et al. [37]
Property Rating Quality criteriaa

Reliability
Internal consistency ? (Sub)scale unidimensional AND Cronbach’s alpha(s) C0.70
? Dimensionality not known OR Cronbach’s alpha not determined
- (Sub)scale not unidimensional OR Cronbach’s alpha(s) \0.70
Measurement error ? MIC [ SDC OR MIC outside the LOA
? MIC not defined
- MIC B SDC OR MIC equals or inside LOA
Reliability ? ICC/weighted Kappa C0.70 OR Pearson’s r C0.80
? Neither ICC/weighted Kappa, nor Pearson’s r determined
- ICC/weighted Kappa \0.70 OR Pearson’s r \0.80
Validity
Content validity ? The target population considers all items in the questionnaire to be
relevant AND considers the questionnaire to be complete
? No target population involvement OR no assessment of completeness
or comprehensivenessa
- The target population considers items in the questionnaire to be
irrelevant OR considers the questionnaire to be incomplete
Construct validity
Structural validity ? Factors should explain at least 50 % of the variance OR good or
adequate fit by goodness-of-fit criteria for a CFA or EFAa,b
? Explained variance not mentioned OR equivocal fit by goodness-of-fit
criteria for a CFA or EFAa,b
- Factors explain \50 % of the variance OR poor fit by goodness-of-fit
criteria for a CFA or EFAa,b
Hypothesis testing ? Correlation with an instrument measuring the same construct C0.50
OR at least 75 % of the results are in accordance with the
hypotheses AND correlation with related constructs is higher than
with unrelated constructs OR no evidence of DIFa
? Solely correlations determined with unrelated constructs OR C50 %
but\75 % of the results are in accordance with the hypothesesa OR
possible DIFa
- Correlation with an instrument measuring the same construct \0.50
OR\50 % of the results are in accordance with the hypothesesa OR
correlation with related constructs is lower than with unrelated
constructs OR notable evidence of DIFa
Responsiveness
Responsiveness ? Correlation of changes with an instrument measuring change in the
same construct C0.50 OR at least 75 % of the results are in
accordance with the hypotheses OR AUC C0.70 AND correlation of
changes with related constructs is higher than with unrelated
constructs
? Solely correlations determined with unrelated constructs
- Correlation of changes with an instrument measuring change in the
same construct \0.50 OR \75 % of the results are in accordance
with the hypotheses OR AUC\0.70 OR correlation of changes with
related constructs is lower than with unrelated constructs
MIC minimal important change, SDC smallest detectable change, LOA limits of agreement, ICC intraclass correlation coefficient, DIF differ-
ential item functioning, AUC area under the curve
? Positive rating, ? indeterminate rating, - negative rating
a
Quality criteria are from [37], with modifications by the authors indicated by italics
b
Good or adequate fit: comparative fit index (CFI) C0.90, root mean square error of approximation (RMSEA) B0.08, standardized root mean
square residual (SRMR) \0.10 [83–85]; Inadequate fit: CFI B0.85, RMSEA C0.10, SRMR C0.10; Indeterminate fit: the values of fit indexes
ranged in between the adequate criteria and inadequate criteria

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Table 2 Levels of evidence for the overall quality of the measurement properties
Level Rating Criteria

Strong ??? or - - - Consistent findings in multiple studies of good methodological quality

OR in one study of excellent methodological quality
Moderate ?? or -- Consistent findings in multiple studies of fair methodological quality
OR in one study of good methodological quality
Limited ? or - One study of fair methodological quality
Conflicting ± Conflicting findings from studies of comparable quality
Indeterminate ? Findings from excellent, good or fair studies were not definitively
positive or negative
None na Findings from excellent, good or fair were not available
Table adapted from Van Tulder et al. [38]: ?positive result; -negative result; ±both positive and negative findings have been reported by
studies of adequate quality; ? findings from studies of adequate quality were not definitively positive or negative; na findings from studies of
adequate quality were not available

Articles retrieved by search strategy:

n=2,588
Excluded (n=2,442)
- Irrelevant studies
- Clinical trials with mindfulness-based intervention

Articles selected based on

Excluded (n=67)
title and abstract: n=146 - Not full text original article (n=12)
- Not mindfulness-specific measures (n=15)
- Not targeting adults (n=8)
- Not designed to evaluate psychometric properties as
a primary focus(n= 32)
Articles selected based on full text: n=79
Excluded (n=33)a
- Translated version (n=25)
- Short/modified version (n=13)
Articles reviewed: n=46b
- MAAS: n=20
- FFMQ: n=12
- KIMS: n=10
- FMI: n=4
- CAMS-R: n=3
- SMQ: n=2
- TMS: n=2
- EQ: n=1
- MMS: n=1
- PHLMS: n=1
a
Several papers included both translated and created a short/or modified version.
b
Several papers reviewed multiple scales and/or contained multiple studies.

Fig. 1 Flowchart of the search strategy and selection of articles

test–retest reliability was adequate (r’s ranging from 0.81 KIMS subscales had different levels of evidence to support
to 0.86) for all but the Observe subscale (r = 0.65) [50]. their construct validity. Accept without Judgment has
The construct validity of the KIMS global score was sup- consistently been found to be the most robust subscale,
ported by moderate correlations (r’s ranging from 0.51 to with most a priori relationships with health and quality of
0.67) with the MAAS, FMI, and CAMS-R and positive life measures confirmed [45, 47, 50–52]. There was also
correlations with meditation experience [44]. Consistent moderate evidence of the construct validity of the Act with
with expectations for convergent and divergent validity, the Awareness subscale. Evidence to support the construct
global KIMS had positive correlations with openness, validity of the Describe subscale was limited, and rela-
emotional intelligence, and self-compassion, and negative tionships with the Observe subscale have been unpredict-
correlations with psychological symptoms, neuroticism, able. For example, the Observe subscale did not differ
alexithymia, dissociation, and absent-mindedness [44]. between adults with borderline personality disorder and

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Table 3 Characteristics of the included studies

Study Population Sample size Age, mean (SD) Female Country
(%)

Argus and Thomson [86] Patients with depression 141 43 (14) 68 Australia
Baer et al. [50] Substudy 1: Psychologists/doctoral 5/6 nr 100/50 US
students in clinical psychology
Substudy 2 and substudy 6: 205/215/26 mostly 18–22 about US
Undergraduates (sample 1)/ (nr)/nr/36 (nr) 60/nr/96
undergraduates (sample 2)/adults
with borderline personality disorder
(sample 3)
Substudy 3: Subset of sample 2 49 nr nr US
Substudy 4: Subset of sample 1 130 20 (nr) 56 US
Substudy 5: Undergraduates 115 nr nr US
Baer et al. [44] Substudy 1 and substudy 2: 613 21 (nr) 70 US
Undergraduates 268 19 (nr) 77 US
Substudy 3: Undergraduates 881 20 (nr) 72 US
Substudy 4: Samples from substudy 1,
substudy 2, and substudy 3
Baer et al. [59] Undergraduates/community 259/293/ 19 (3)/50 (7)/ 78/60/ US/UK/US/US
participants/non-meditators/ 252/213 44 (12)/49 (13) 58/68
meditators
Baer et al. [68] Meditators 115 46 (12) 73 US
Non-meditators 115 44 (12) 63 US
Barnes and Lynn [63] Undergraduates 145 19 (2) 69 US
Baum et al. [87] Patients with recurrent depression 100 48 (11) 77 England
Bernstein et al. [88] Adults with traumatic events 76 30 (13) 46 US
Brown and Ryan [15] Study: Undergraduates/ 313/327/239/ 20 (nr)/20 (nr)/ 66/64/66/ US
undergraduates/general adults/ 60 43 (nr)/19 (nr) 57
undergraduates
Substudy 1: Undergraduates, general 74 to 1,046 19 to 23 (nr) 55 to 66 US
adults
Substudy 2: Community meditators 100 41 (nr) 29 US
and non-meditators
Substudy 3: Undergraduates 90 20 (nr) 66 US
Substudy 4: Community participants/ 74/92 38 (nr)/20 (nr) 55/74 US
undergraduates
Substudy 5: Patients with breast or 41 55 (10) 78 US
prostate cancer
Buchheld et al. [53] Retreat participants 115 43 (nr) 69 German
Cardaciotto et al. [73] Substudy 1: Mindfulness experts 6 nr 33 US
Substudy 2: Undergraduates 204 22 (4) 52 US
Substudy 3: Undergraduates 559 20 (4) 51 US
Substudy 4: Outpatients in psychiatry 52 41 (12) 56 US
Substudy 5: Inpatients with eating 30 30 (11) 90 US
disorders 78 26 (8) 89 US
Substudy 6: Graduate students seeking
psychotherapy
Carlson and Brown [39] Outpatients with cancer 122 50 (13) 67 Canada
Community participants 122 48 (16) 67 Canada
Cash and Whittingham [64] Community participants 106 36 (16) 59 Australia

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Table 3 continued
Study Population Sample size Age, mean (SD) Female Country
(%)

Chadwick et al. [58] Community participants: Non- 51 47 (nr) 75 England

meditators 83 47 (nr) 60 England
Community participants: Meditators 122 31 (nr) 36 England
Patients with psychosis
Christopher et al. [41]a Undergraduates 365 22 (6) 71 US
Christopher and Gilbert [45] Undergraduates 365 22 (6) 71 US
Christopher et al. [60] Adults online (meditators and non- 349 32 (12) 75 US
meditators)
Cordon and Finney [43] Securely attached undergraduates 228 19 (1) 77 US
Insecurely attached undergraduates 267 19 (1) 77 US
Davis et al. [70] Community participants 369 40 (14) 65 Australia
Undergraduates 92 22 (7) 80 Australia
Emanuel et al. [89] Undergraduates: online responders 109 23 (nr) 78 US
Undergraduates: paper responders 111 nr nr US
Feldman et al. [57] Substudy 1: Undergraduates/ 250/298 19 (3)/19 (2) 64/61 US
undergraduates 212 19 (2) 60 US
Substudy 2: Undergraduates
Fernandez et al. [61] Undergraduates 316 22 (0.4) 92 US
Fisak and von Lehe [66] Undergraduates 400 22 (5) 69 US
Fresco et al. [71] Substudy 1: Undergraduates/ 1,150/519 19 (4)/19 (2) 67/65 US/US
undergraduates 61 20 (3) 56 US
Substudy 2: Undergraduates 220 versus 50 44 (10) versus 45 75 versus England, Wales,
Substudy 3: Patients with depression (9) 74 Canada versus
versus Healthy control England
Frewen et al. [47] Substudy 1: Undergraduates 64 nr 73 Canada
Substudy 2: Undergraduates 43 nr 70 Canada
a
Ghorbani et al. [46] Undergraduates: Three samples 256/298/346 20 (5)/19 (3)/20 37/68/54 US
(3)
Haigh et al. [72] Undergraduates (sample 1)/ 582/457/451 19 (4)/23 (10)/22 69/60/69 US
undergraduates (sample 2)/ (nr)
undergraduates (subset of sample
1 ? subset of sample 2)
Herndon [90] Undergraduates 142 nr nr US
Hollis-Walker and Colosimo Undergraduates and demographically 123 21 (nr) 78 Canada
[62] similar community participants
Lau et al. [69] Substudy 1: General adults 390 41 (13) 55 Canada
(Meditators ? Non-meditators) (232 ? 158)
Substudy 2: Patients with psychiatric 123 47 (13) 68 Canada
or medical conditions
Lavender et al. [65] Undergraduate women 276 20 (3) 100 US
Leigh et al. [55] Undergraduates 196 nr 63 US
MacKillop and Anderson [40] Undergraduates 711 Mostly 18–19 (nr) 53 US
McCracken et al. [91] Patients with pain 105 47 (13) 60 UK
McCracken and Patients with pain 150b 47 (13) 64 UK
Thompson [92]
McKee et al. [93] Community participants 154 22 (8) 57 US
Roemer et al. [94] Substudy 1: University commuters 411 23 (nr) 64 US
Substudy 2: Clinical sample 16 versus 16 33 (12) versus 31 69 versus US
diagnosed with generalized anxiety (9) 69
disorder versus control

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Table 3 continued
Study Population Sample size Age, mean (SD) Female Country
(%)

Schmertz et al. [49] Undergraduates 50 20 (3) 82 US

Van Dam et al. [67] Undergraduates: Non-meditators/ 263/58 19 (1)/48 (14) 48/64 US
meditators
Van Dam et al. [42] Undergraduates 414 20 (3) 67 US
Vujanovic et al. [95] Community participants 248 22 (8) 55 US
Vujanovic et al. [51] Adults with traumatic life events 239 23 (10) 54 US
Vujanovic et al. [52] Non-clinical community young adults 193 24 (10) 55 US
Walach et al. [54] Meditators/general adults/clinical 85/85/117 44 (9)/34 (12)/nr 66/55/nr German
sample with psychiatric conditions
Waters et al. [48] Adult smokers 158 44 (12) 45 US
Zvolensky et al. [96] Community participants 170 22 (8) 56 US
nr not reported
a
Studies were limited to English speaking students
b
Includes the sample from McCracken et al. [91]; the 2009 findings addressed in this review were limited to properties not assessed in the 2007
report

normative student samples [50]. The developers acknowl- knowledge, and negatively correlated with psychological
edged limitations in the content coverage of the KIMS and symptoms, neuroticism, difficulties in emotion regulation,
concerns about integration of the subscales to provide a alexithymia, dissociation, and distress [44, 54]. However,
meaningful global score. there was an unexpected positive relationship between FMI
scores and smoking/frequent binge-drinking among
Freiburg Mindfulness Inventory (FMI) undergraduate college students, suggesting that the FMI
may not be valid when completed by persons without some
The FMI was originally developed and validated in familiarity or experience with insight meditation [55]. This
German, and English translations of FMI items have been review pooled the findings from the original German ver-
incorporated into more recently developed mindfulness sion of the FMI [53, 54] with those of its English transla-
instruments [44]. Buddhist psychology guided develop- tion [44, 55] because of the importance of the FMI as the
ment of the FMI and its intended target audience was first insight meditation-inspired self-report measure of
individuals with some knowledge about or familiarity with mindfulness published.
insight meditation. The FMI was designed to assess
mindfulness as ‘‘attentional, unbiased observation of any Cognitive and Affective Mindfulness Scale-Revised
phenomenon in order to perceive and to experience how it (CAMS-R)
truly is, absent of emotional or intellectual distortion’’ [53].
The developers cited the hallmark of mindfulness as dis- The CAMS-R was designed to measure mindfulness in a
passionate, non-manipulative participant observation of brief, jargon-free, and conceptually comprehensive way,
ongoing mental states without conceptualizing or forming with the intention that it would be a generic measure
emotional reactions. EFA identified 4 factors for the FMI; appropriate regardless of meditation experience. Based on
however, the structure was not stable across samples and Kabat-Zinn’s definition [56], ‘‘awareness that emerges
items cross-loaded, which the authors interpreted as sup- through paying attention on purpose, in the present
port for a single underlying factor [53]. This original moment, and non-judgmentally to the unfolding of expe-
4-factor structure was only approximately replicated in a rience moment to moment,’’ the authors conceptualized
subsequent study [54], and these authors also favored mindfulness as having four aspects: attention, present-
interpreting the FMI as one general factor reflecting focus, awareness, and acceptance/non-judgment [57].
mindfulness. There was evidence to support the internal Factor analyses provided moderate evidence of the pre-
consistency of the global FMI (Cronbach’s alphas ranged dicted four aspects reflecting an overarching construct of
from 0.80 to 0.94). The FMI had weak to moderate cor- mindfulness [57]. There was evidence of the internal
relations with the MAAS, KIMS, CAMS-R, and SMQ consistency of the CAMS-R (Cronbach’s alphas ranging
(r’s = 0.31 to 0.60) [44]. As expected, the FMI was pos- from 0.61 to 0.81). The CAMS-R had moderate correla-
itively correlated with openness, self-compassion, and self- tions with other measures of mindfulness, including

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Table 4 Characteristics of the included instruments

Instrument Construct Recall Dimensions Number Response Ease of scoring and Sample items
assesseda period (number of of options (range) administration (range
items) subscales of scores)

MAAS Dispositional None One dimension None 6-point scale Easyb ‘‘I find myself doing
Mindfulness Total (15) (1 = almost (1–6) things without paying
always to attention,’’ and ‘‘I do
6 = almost jobs or tasks
never) automatically, without
being aware of what I’m
doing’’
KIMS Mindfulness None Observe (12) 4 5-point scale Easy ‘‘I notice the smells and
skills Describe (8) (1 = never or (Observe: 12–72, aromas of things’’
very rarely Describe: 8–48, Act (Observe); ‘‘I’m good at
Act with
true to with Awareness: finding the words to
Awareness
6 = almost 10–60, Accept without describe my feelings’’
(10)
always or Judgment: 9–54) (Describe); ‘‘When I do
Accept without things, my mind
always true)
Judgment (9) wanders off and I’m
Total (39) easily distracted’’ (Act
with Awareness); and ‘‘I
tell myself that I
shouldn’t be feeling the
way I’m feeling’’
(Accept without
Judgment)
FMI Mindfulness Time frame Present-moment None 4-point scale Easy ‘‘I am open to the
to be set by disidentifying (1 = almost (30–120) experience of the
user attention (12) never to present moment,’’ and
Non- 4 = almost ‘‘I perceive my feelings
judgmental, always) and emotions without
non-evaluative having to react to
attitude them.’’
toward self
and others (7)
Openness to
negative mind
states (7)
Process-
oriented,
insightful
understanding
(4)
Total (30)
CAMS-R Mindfulness None Attention (3) None 4-point scale Easy ‘‘It is easy for me to
Present-focus (1 = rarely/not (12–48) concentrate on what I
(3) at all to am doing,’’ and ‘‘I am
4 = almost able to focus on the
Awareness (3)
always) present moment’’
Acceptance/
non-judgment
(3)
Total (12)
SMQ Mindfulness None One dimension None 7-point scale Easy All items start with
Total (16) (0 = strongly (0–96) ‘‘Usually when I
disagree to experience distressing
6 = strongly thoughts and images…’’
agree) and items include, ‘‘I
am able just to notice
them without reacting,’’
and ‘‘I am able to accept
the experience’’

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Table 4 continued
Instrument Construct Recall Dimensions Number Response Ease of scoring and Sample items
assesseda period (number of of options (range) administration (range
items) subscales of scores)

FFMQ Mindfulness None Observing (8) 5 5-point scale Easy ‘‘I pay attention to
Describing (8) (1 = never or (Observing: 8–40, sensations such as the
very rarely Describing: 8–40, wind in my hair or sun
Acting with
true to Acting with on my face’’
Awareness (8)
5 = very Awareness: 8–40, (Observing); ‘‘I have
Non-judging of trouble thinking of the
often or Non-judging of
experience (8) right words to express
always true) experience: 8–40,
Non-reactivity Non-reactivity to how I feel about things’’
to experience experience: 7–35) (Describing); ‘‘I rush
(7) through activities
without being really
Total (39)
attentive to them’’
(Acting with
Awareness); ‘‘I make
judgments about
whether my thoughts
are good or bad’’ (Non-
judging of experience);
and ‘‘I watch my
feelings without getting
lost in them’’ (Non-
reactivity to experience)
TMS Mindfulness Respondents Curiosity (6) 2 5-point scale Moderatec (Curiosity: ‘‘I was curious about my
are Decentering (7) (0 = not at all 0–24, Decentering: reactions to things,’’
instructed to 4 = very 0–28) (Curiosity) and ‘‘I was
to rate a much) aware of my thoughts
15-min and feelings without
meditation overidentifying with
experience them’’ (Decentering)
EQ Decentering None One dimension None 5-point scale Easy (11–55) ‘‘I am better able to
Total (11) (1 = never to accept myself as I am,’’
5 = all the and ‘‘I can observe
time) unpleasant feelings
without being drawn
into them’’
MMS Mindfulness None Novelty Seeking 4 7-point scale Easy ‘‘I like to investigate
(6) (1 = strongly (Novelty Seeking: 6–42, things’’ (Novelty
Novelty disagree to Novelty Producing: Seeking); ‘‘I try to think
Producing (6) 7 = strongly 6–42, Engagement: of new ways of doing
agree) 5–35, Flexibility: things’’ (Novelty
Engagement (5)
4–28) Producing); ‘‘I get
Flexibility (4) involved in almost
Total (21) everything I do’’
(Engagement); and ‘‘I
stay with the old tried
and true ways of doing
things’’ (Flexibility)
PHLMS Mindfulness One week Awareness (10) 2 5-point scale Awareness: easy ‘‘When I am startled, I
Acceptance (10) (1 = never to (10–50) notice what is going on
5 = very Acceptance: easy inside my body,’’
often) (10–50)d (Awareness) and
‘‘There are things I try
not to think about’’
(Acceptance)
a
Higher scores represent higher levels of construct
b
Average of total summed items
c
Requires a delivery of 15-min meditation period prior to administration
d
Sum of the reversed scores

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Table 5 Methodological quality of each study per measurement property and instrument
Internal Reliability Content Structural Hypotheses Responsiveness
consistency validity validity testing

MAAS
Brown and Ryan [15] Goodc Goodc Faira Goodb
Brown and Ryan—substudy 1 [15] Fairc
Brown and Ryan—substudy 2 [15] Goodc
c
Brown and Ryan—substudy 3 [15] Good Goodc
c
Brown and Ryan—substudy 4 [15] Good Goodc
Brown and Ryan—substudy 5 [15] Fairc Fairc
Carlson and Brown [39] Goodc Good c
Good c

Baer et al. [44] Goodc Goodc

Zvolensky et al. [96] Fairc
c c
MacKillop and Anderson [40] Excellent Excellent Goodc
McCracken et al. [91] Goodc Goodc
Vujanovic et al. [95] Fairc
c
Argus and Thomson [86] Good Fairc
c c
Cordon and Finney [43] Good Good Fairc
c c
Frewen et al.—substudy 1 [47] Good Poor Goodc
Frewen et al.—substudy 2 [47] Fairc Poorc Fairc
c
Herndon [90] Fair Fairc
c
Christopher et al. [41] Fair
Ghorbani et al. [46] Goodc Goodc Goodc
c
McCracken and Thomps [92] Good
Roemer et al.—substudy 1 [94] Goodc Goodc
Roemer et al.—substudy 2 [94] Fairc Fairc
Schmertz et al. [49] Goodc Fairc
Waters et al. [48] Goodc
c
Christopher and Gilbert [45] Good Goodc
c c
Van Dam et al. [42] Excellent Fair
Bernstein et al. [88] Goodc
KIMS
Baer et al.—substudy 1 [50] Faird
e
Baer et al.—substudy 2 [50] Good Goode
e
Baer et al.—substudy 3 [50] Fair
Baer et al.—substudy 4 [50] Faire
Baer et al.—substudy 5 [50] Goode
Baer et al.—substudy 6 [50] Faire
e
Baer et al. [44] Good Goode
McKee et al. [93] Goode
e e
Frewen et al.—substudy 1 [47] Good Poor Faire
Frewen et al.—substudy 2 [47] Faire Poore Faire
Christopher et al. [41] Faire
Vujanovic et al. [51] Goode
Waters et al. [48] Goode
e
Baum et al. [87] Good
Christopher and Gilbert [45] Goode Goode
Vujanovic et al. [52] Goode
FMI
Buchheld et al. [53] Good Fair

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Table 5 continued
Internal Reliability Content Structural Hypotheses Responsiveness
consistency validity validity testing

Leigh et al. [55] Good Good Fair

Baer et al. [44] Good Good
Walach et al. [54] Excellent Good Good
CAMS-R
Baer et al. [44] Good Good
Feldman et al.—substudy 1 [57] Good Good
Feldman et al.—substudy 2 [57] Good Good
Schmertz et al. [49] Fair Fair
SMQ
Baer et al. [44] Good Good
Chadwick et al. [58] Good Good Fair
FFMQ
Baer et al. [44] Good Good Good
Baer et al. [59] Good Good Good
Van Dam et al. [67] Poor Fair
Barnes and Lynn [63] Good Fair
Cash and Whittingham [64] Good
Emanuel et al. [89] Good Fair
Fernandez et al. [61] Good Good Fair
Baer et al. [68] Good
Hollis-Walker and Colosimo [62] Good
Lavender et al. [65] Good Good
Christopher et al. [60] Good Good Fair
Fisak and von Lehe [66] Good Good
TMS
Lau et al. [69] Poor
Lau et al.—substudy 1 [69] Good Good Good
Lau et al.—substudy 2 [69] Good Good
Davis et al. [70] Good Good
EQ
Fresco et al.—substudy 1 [71] Good Good
Fresco et al.—substudy 2 [71] Good
Fresco et al.—substudy 3 [71] Good Good Good
MMS
Haigh et al. [72] Excellent Excellent
PHLMS
Cardaciotto et al.—substudy 1 [73] Fairf
Cardaciotto et al.—substudy 2 [73] Goodg
Cardaciotto et al.—substudy 3 [73] Goodg Goodg Goodg
Cardaciotto et al.—substudy 4 [73] Fairg Goodg
Cardaciotto et al.—substudy 5 [73] Fairg Fairg
g
Cardaciotto et al.—substudy 6 [73] Fair Goodg
The original COSMIN checklist was modified so that studies could receive an overall rating of good, if the only flaw noted was inadequate
reporting of the methods for handling missing data
a b c
Assessed with a pool of 184 items, with a set of 24 items, and with the final 15 items
d e
Assessed with a pool of 77 items, and with the final 39 items
f g
Assessed with a pool of 105 items, and with the final 20 items

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MAAS, FMI, KIMS, and SMQ (r’s = 0.51 to 0.67) [44, Others have shown a modest fit for this structure [61] and
57]. Construct validity was supported by positive rela- hierarchical models that supported only four factors (all but
tionships with measures of adaptive regulation, openness, Observe) as facets of an overarching mindfulness construct
and well-being, and negative relationships with neuroti- in student samples [44]. Internal consistency of the FFMQ
cism, difficulties in emotion regulation, dissociation, and is adequate with Cronbach’s alphas for the five subscales
stagnant deliberation [44]. The CAMS-R, and not the ori- ranging from 0.67 to 0.93. Construct validity for the global
ginal CAMS, was included in this review, because the FFMQ and its subscales has been evidenced by positive
developers determined that the CAMS was seriously correlations with openness, emotional intelligence, self-
flawed, and do not support its use [57]. compassion, and well-being, and negative correlations with
neuroticism, depression, anxiety, alexithymia, and disso-
Southampton Mindfulness Questionnaire (SMQ) ciation [44, 62–66]. Meditators scored higher on the FFMQ
than non-meditating students, and meditation history was
The SMQ was designed to assess the awareness of distressing correlated with a total FFMQ score in meditating samples
thoughts and images defined as a concept consisting of four (r = 0.52) [67]. The FFMQ Observe and Describe sub-
related constructs: awareness of cognitions as mental events in scales were derived largely from the KIMS, and as with the
wider context, allowing attention to remain with difficult KIMS, relationships with these subscales were less robust
conditions, accepting such difficult thoughts and oneself and predictable than those with other facets. For example,
without judging, and letting difficult cognitions pass without significant differences in Observe and Describe were not
reactions such as rumination [58]. Although factor analysis found between high- and low-worry groups [66]. There was
suggested a single-factor structure for the SMQ, a single-factor little or no evidence for differential item functioning (DIF)
solution explained less than 50 % of the variance [58]. There between meditators and non-meditators matched for age
was evidence of the internal consistency of the SMQ (Cron- [68], although the developers previously found that the
bach’s alphas ranging from 0.82 to 0.89). Correlations between structure of the FFMQ, particularly with respect to the
the SMQ and other measures of mindfulness varied from weak Observe facet, differed between meditators and non-med-
to moderate (r’s = 0.38 to 0.61) [44, 58]. Consistent with itators [44].
expectations, the SMQ correlated positively with emotional
intelligence and self-compassion, and negatively with neu- Toronto Mindfulness Scale (TMS)
roticism, difficulties in emotion regulation, alexithymia, dis-
sociation, and negative affect [44, 58]. SMQ scores were The TMS was designed to assess mindfulness as a ‘‘quality
higher in meditators compared with non-meditators and in maintained when attention is intentionally cultivated with
non-clinical samples compared to patients with psychosis [58]. an open, non-judgmental orientation to experience’’ [69].
The original TMS measures mindfulness as a state-like
Five Facet Mindfulness Questionnaire (FFMQ) quality, and not as a trait. The administration of the TMS
requires that a brief mindfulness exercise precedes self-
The FFMQ was derived from factor analysis of the com- administration of the instrument, and the TMS items assess
bined item pool from five independently developed mind- the quality of that experience. The TMS is composed of
fulness instruments: MAAS, KIMS, FMI, CAMS-R, and two subscales, Curiosity and Decentering, and a total TMS
SMQ [44]. The FFMQ has four facets similar to those of score is not reported. EFA suggested a 2-factor structure
the KIMS (Observing, Describing, Acting with Awareness, for the TMS, and this was supported by CFA [69]. The
and Non-judging of inner experience) and one more facet TMS had evidence of internal consistency with Cronbach’s
comprised of items from the FMI and SMQ (Non-reactivity alphas ranging from 0.86 to 0.91, and 0.85 to 0.87 for
to inner experience). The authors found that the relation- Curiosity and Decentering, respectively. Correlations for
ship between the facets and an overarching construct of the Decentering subscale with most of the other measures
mindfulness differed based on meditation experience and of mindfulness, including MAAS, FMI, CAMS-R, SMQ,
that associations with symptoms and other constructs dif- KIMS subscales, and FFMQ subscales (r’s = 0.20–0.74),
fered by facet. Therefore, they suggested use of the indi- were stronger than the correlations between the Curiosity
vidual subscales may be preferred to the use of the total subscale and these measures (r’s = 0.10–0.54) [70].
FFMQ score. A 5-factor structure for the FFMQ was sug- Curiosity and Decentering were positively correlated with
gested by EFA [44] and confirmed by good or acceptable absorption, awareness of surroundings, reflective self-
fit indexes in CFA using the same parceling approach for awareness, and psychological mindedness. As hypothe-
CFA employed in developing the KIMS [50, 59]. A recent, sized, only Curiosity was correlated with awareness of
standard item-level CFA supported the original 5-factor internal states and self-consciousness (r = 0.41 and 0.31),
structure and an overarching mindfulness factor [60]. and only Decentering was correlated with openness and

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cognitive failures (r = 0.23 and -0.16) [69]. Curiosity and external experiences in the context of an accepting, non-
Decentering scores were higher in meditators than non- judgmental stance toward those experiences’’ [73]. This
meditators, and scores for the Decentering subscale were definition was operationalized as two constructs: Aware-
shown to increase with meditation experience [70]. Chan- ness—a behavioral tendency of continuously monitoring
ges in Decentering were associated with changes in current experience—and Acceptance—a stance of experi-
symptoms and stress [69]. encing events, including cognitions, without judgments and
reactions such as interpretation, elaboration, or avoidance.
Experiences Questionnaire (EQ) The subscales were shown to be uncorrelated, and the use
of a total PHLMS score is not recommended. A 2-factor
The EQ was designed to measure Decentering, a construct structure for the PHLMS was supported by CFA [73].
described as the ability to adopt a wider perspective where Internal consistency was also supported with Cronbach’s
one’s thoughts are viewed as separate from oneself, and not alphas ranging from 0.75 to 0.86 and 0.75 to 0.91 for
necessarily an objective reflection of reality [71]. Decen- Awareness and Acceptance, respectively. Evidence of
tering is posited to be a major outcome of mindfulness-based construct validity was mixed [73]. For example, the
cognitive therapy and a mechanism that enables patients to Awareness subscale was strongly correlated with the KIMS
be resilient to depressive thoughts. The authors did not view Observe subscale (r = 0.83), and the Acceptance subscale
Decentering as synonymous with mindfulness, but closely was strongly correlated with the KIMS Accept without
related or a component of mindfulness. The EQ was origi- Judgment subscale (r = 0.79) [73]. However, the correla-
nally designed to have items reflecting Decentering and tion between the Awareness subscale and MAAS was weak
rumination; however, the structure was determined to be (r = 0.21) for student samples and moderate (r = 0.40) for
unifactorial for the construct of Decentering [71]. The EQ psychiatry outpatients. The correlation between the
had evidence of internal consistency (Cronbach’s alphas Acceptance subscale and MAAS was also weak (r = 0.32)
ranging from 0.83 to 0.90), and construct validity was sup- for the normative student samples. As expected, student
ported by positive correlations with cognitive appraisal samples scored higher on both PHLMS subscales than
(r = 0.25) and negative correlations with experiential psychiatry outpatients, and students scored higher on the
avoidance, brooding rumination, emotional suppression, Acceptance subscale compared to the inpatients with eating
current depression, and anxiety symptoms (|r|’s = 0.31 to disorders (EDs). However, Awareness scores were not
0.49) [71]. Patients with depression had lower levels of significantly different between students and inpatients
Decentering compared to healthy controls [71]. with EDs.

Mindfulness/Mindlessness Scale (MMS)

Discussion
The MMS was designed to assess mindfulness from a
cognitive-information processing framework as active The purpose of this study was to systematically assess and
awareness of and engagement with the environment [72]. compare the properties of instruments to measure self-
Its Western cognitive derivation distinguishes the MMS reported mindfulness in adults. A comprehensive search
from the other measures presented in this review. The strategy identified a total of 2,588 potentially relevant
MMS is composed of four subscales: Novelty Seeking, articles. Out of this pool, 46 articles reporting 79 unique
Engagement, Novelty Producing, and Flexibility. The studies met the inclusion criteria for review. Ten instru-
4-factor structure has not been supported, and a 2-factor ments quantifying mindfulness as a unidimensional scale
structure explaining 34 % of the variance has been reported (n = 5) or as a set of 2–5 subscales (n = 5) were found.
[72]. Evidence of internal consistency was positive for the The COSMIN checklist was used to evaluate the method-
MMS as a single scale with Cronbach’s alphas ranging ological quality of each study for six properties in the
from 0.81 to 0.86. Cronbach’s alphas for the MMS sub- COSMIN taxonomy: internal consistency, reliability, con-
scales ranged from 0.45 to 0.77. There was mixed evidence tent validity, structural validity, hypothesis testing, and
regarding the relationships between MMS items and mea- responsiveness. We had initially planned to address mea-
sures of mood. surement error, but no study evaluated this measurement
property. The methodological quality of the studies inclu-
ded in this review was mostly good (66 %) or fair (26 %)
Philadelphia Mindfulness Scale (PHLMS) across all properties. The majority of the studies were
conducted with college undergraduates (48 out of 79
The PHLMS was designed to assess mindfulness defined as studies). No instrument had evidence to support content
‘‘the tendency to be highly aware of one’s internal and validity or adequacy of measurement error. The MAAS

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Table 6 Quality of measurement properties per instrument

Instrument Internal consistency Reliability Content validity Structural validity Hypothesis testing Responsiveness

MAAS ??? ?? ? ± ??? ?

KIMS ??? ?a ? ? ??b na
FMI ??? na na ? ± na
CAMS-R ?? na na ?? ?? na
SMQ ??? na na -- ± na
FFMQ ??? na na ? ???c na
TMS ??? na ? ?? ?? ?d
EQ ??? na na ??? ??? na
MMS ???e na na --- na na
PHLMS ??? na ? ?? ± na
There was no evidence to evaluate measurement error for these instruments
a
Test–retest results were adequate for 3 of 4 subscales
b
Rating for the global score is ??; ratings for subscales range from ??? for Accept without Judgment to -for Observe
c
Ratings for subscales Observe and Describe are less often consistently positive than ratings for the other subscales
d
One of the two subscales has been shown to be responsive
e
This was evaluated with the whole MMS score only

was the most frequently evaluated instrument followed by population for item development and pretesting. Cognitive
the KIMS. The MAAS was supported by positive evidence interviews or focus groups to evaluate understanding and
for internal consistency, reliability, construct validity by relevance to the target population or comprehensiveness of
hypothesis testing, and responsiveness. The KIMS was the items for the construct of mindfulness were not con-
supported by strong evidence for internal consistency, ducted. Neither was there any exploration of potential
moderate evidence for construct validity by hypothesis ‘‘response shift’’ in understanding of the construct of
testing, and limited evidence for reliability, but the other mindfulness following meditation training [74]. Moreover,
measurement properties were indeterminate or not avail- the lack of diversity among the samples used in psycho-
able. The results shown in Table 6 provide limited guid- metric testing severely restricted the capacity of developers
ance for instrument selection. The MAAS, KIMS, to detect potentially important differences among persons.
CAMS-R, FFMQ, TMS, EQ, and PHLMS were found to It is unknown whether items have very different semantic
have moderate or strong positive results for two or more interpretations depending on the respondent’s characteris-
properties; these measures may be preferred on psycho- tics, for example, health status, age, and race. Conceptual
metric grounds over the other instruments. Final instrument differences and lack of content validity were evidenced by
selection must consider other factors including the con- weak to modest correlations among these measures of
ceptual definition, completion time, and target population. mindfulness and among similarly titled mindfulness sub-
Moreover, as described below, there are areas where all the scales. These gaps are consistent with a general lack of
instruments are lacking; therefore, caution is advised in empirical studies comparing the psychometric perfor-
using these results. mances of competing patient-reported outcome (PRO)
Descriptive critiques of mindfulness instruments have measures within a complementary and alternative medicine
identified key problems, including (1) important differ- (CAM) setting [75]. As no degree of superlative perfor-
ences in conceptual definitions of mindfulness; (2) no mance on other psychometric properties can compensate
confirmation of respondent understanding of items; (3) for poor content validity [76], none of the measures eval-
absence of investigation of the potential discrepancies uated can be strongly recommended as a PRO at this time.
between self-reports and external referents (e.g., indicators It is not clear as to which mindfulness instrument rep-
of mindfulness experimentally tested or observed by oth- resents all the essential aspects of mindfulness. Some facets
ers); and 4) conflation of the effects of learning the lan- or dimensions of mindfulness may be more tractable to
guage of mindfulness or valuing mindfulness with actual self-reports, and facets vary in their relationships with
increases in mindfulness per se [24, 25]. To a great extent, clinically relevant outcomes. ‘‘Summing up’’ purported
these problems are direct consequences of inadequate facets of mindfulness as often done with the KIMS or
content validation. As documented by this systematic FFMQ is likely to be problematic since some individuals
review, there was no engagement with members of a target who appear to possess higher levels of mindfulness could

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actually have a ‘‘toxic’’ combination of mental behaviors, paper by Terwee et al. [37], rely heavily upon classical test
such as being highly aware and very judgmental [16, 25, theory, and lack sufficient guidance for integrating findings
77]. Although cogent arguments have been made for the from item response theory (IRT) into its quality ratings. For
utility of a brief, all-inclusive measure of mindfulness (e.g., example, is an instrument to be down-graded for construct
CAMS-R) for clinical use, others have urged that instru- validity if several of its items are shown to have differential
ments address specific subdomains and be re-titled to better item functioning (DIF), and if so, how many items with
reflect their contents and avoid having a multiplicity of DIF would result in a downgrade?
instruments with very different content all claiming to There are limitations to this study. First, only one
measure mindfulness [25, 78]. investigator conducted the first stage review of the over
2,500 titles and abstracts identified by our search strategy.
Utility of mindfulness scales To verify the completeness of the initial selection, we
relied upon our search of the references of the selected
There is a surprising lack of information to guide users of articles and investigation of citations for the selected
these instruments. Few instruments had information on instruments through the Web of Science. Second, selection
test–retest reliability or responsiveness, and none provided bias may be introduced by including only studies published
evidence of the adequacy of measurement error or esti- in English. We initially excluded all mindfulness instru-
mated a minimally important difference. Floor or ceiling ments not developed in English and then changed our
effects, rates of missing data, average completion time, and criteria to include the German language FMI because of its
skewness of distributions were mentioned rarely or not at importance to the field. We have noted where psychometric
all. For the instruments with subscales, additional guidance findings from the German and English versions have been
regarding whether or not subscales should or should not be pooled. Short forms of these mindfulness instruments were
combined and how those scores should be labeled (e.g., not included [80–82]. We cannot recommend use of any
total or global) and reported (e.g., mean or sum) would short form where the longer version lacks evidence of
promote consistency and facilitate comparisons across content validity; reducing the number of items will not
studies. overcome this serious flaw. Translated instruments were
also not included. These instruments warrant a separate
Use of COSMIN and quality criteria review to adequately address issues of meaning and cross-
cultural validity.
The COSMIN checklist is a useful guide, but has short- In conclusion, self-reports of mindfulness have the
comings. First, benchmarks for sample size are not helpful potential to be an important means of assessing the
for CFA, since they are based on number of items and not mechanisms and outcomes of mindfulness-based therapies.
number of parameters to estimate and do not account for There is a great need to establish the content validity of the
approaches such as bundling items into parcels to over- extant measures of mindfulness using qualitative methods,
come sample size limitations. We also found it necessary to such as semi-structured interviews and focus groups with
better define thresholds for adequate fit of CFA. These are novice and experienced meditators, diverse populations,
listed in the footnote to Table 1. Second, COSMIN weights and clinical populations with acute and chronic illnesses.
reporting and handling of missing data very heavily. Further explication of the construct of mindfulness, its
Studies that do not provide clear information about rates of facets and consequences, and pretesting of items with
missing data and explain how missing data were handled diverse target populations to insure comprehensiveness of
are rated as having no more than fair methodological content coverage, clarity, and relevance are needed. Items
quality on missing data items. We initially followed this prone to bias from learning the language of mindfulness
guideline, and it resulted in 71 % of all studies receiving and recognizing its value should be eliminated. It is timely
overall fair ratings for the property. We felt this under- to devise external referents to validate these self-reports.
represented the overall quality of the studies in this review. External referents may take the form of neuropsychological
We therefore used a modified guideline to allow an overall or other performance tests, evaluations by third-parties,
rating of good, if the only flaw noted was inadequate such as teachers, spouses, or other family members, bio-
reporting of missing data. These are the ratings shown in markers, or imaging studies. Several of the brief, royalty-
Table 5. Nevertheless, inadequate reporting and handling free tests in the cognitive domain of the newly developed
of missing data are problematic [79], and developers NIH Toolbox for Assessment of Neurological and Behav-
should be strongly encouraged to report rates of missing ioral Function (www.nihtoolbox.org) may be useful
data and use robust methods for imputation. external referents for mindfulness. Content validation
It would be timely to update the quality criteria to assess should take precedence over efforts to optimize reliability
measurement properties. These criteria derive from a 2007 and create short forms. Researchers using current

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2656 Qual Life Res (2013) 22:2639–2659

mindfulness instruments are encouraged to report fre- 3. Bohlmeijer, E., Prenger, R., Taal, E., & Cuijpers, P. (2010). The
quencies of skipped items to aid in identifying poor items effects of mindfulness-based stress reduction therapy on mental
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imally important differences. Use of mindfulness-based effect of mindfulness-based therapy on anxiety and depression:
interventions continues to grow, with target populations A meta-analytic review. Journal of Consulting and Clinical
Psychology, 78(2), 169–183.
and use of novel technologies for training rapidly 5. Gross, C. R., Kreitzer, M. J., Thomas, W., Reilly-Spong, M.,
expanding. Research to establish the best approaches for Cramer-Bornemann, M., Nyman, J. A., et al. (2010). Mindful-
mindfulness training and target those most likely to benefit ness-based stress reduction for solid organ transplant recipients:
will be facilitated by valid and reliable self-reported A randomized controlled trial. Alternative Therapies in Health
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Winbush, N. Y., Patterson, R., et al. (2011). Mindfulness-based
Acknowledgments This study was supported in part by National stress reduction versus pharmacotherapy for chronic primary
Institutes of Health, National Institute of Diabetes and Digestive and insomnia: A randomized controlled clinical trial. Explore: The
Kidney diseases grant P01 DK 13083. Journal of Science & Healing, 7(2), 76–87.
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