Experiential avoidance,committed action and quality of life: Differences between college students with and without chronic illness

Abstract

This study aimed to explore, through structural equation modelling, experiential avoidance and committed action’s effects on the association between anxiety and psychological quality of life and whether this relationship presents significant differences across a sample of 115 college students with chronic illness and a sample of 232 students without illness. Students with chronic illness presented higher levels of anxiety and experiential avoidance and lower levels of quality of life. The association between anxiety and psychological quality of life was partially explained by experiential avoidance and committed action. This path model was shown to be invariant between the two groups of students.

Keywords

anxiety chronic illness committed action experiential avoidance quality of life

Introduction

Several studies suggest that there are high rates of anxiety among college students (Andrews and Wilding, 2004; Bayram and Bilgel, 2008). The incidence of anxiety symptoms has been rapidly increasing among college students during the past years (American College Health Association (ACHA), 2008). College students who presented high levels of anxiety show low levels of psychological and physical quality of life (QoL; Blanco et al., 2008; Unalan et al., 2008). Research shows that high levels of anxiety can compromise subjective well-being and lead to impairment in important life areas both in healthy and chronically ill samples (e.g. Pinto-Gouveia et al., 2014). As a result, there has been an increasing interest in understanding the impact that anxiety holds on individuals’ subjective perception of their QoL.

Despite the numerous definitions proposed for QoL, there is a general consensus among experts that the wide-ranging concept of QoL should not be focused only on objective factors (such as health status indicated by a clinician) but also on self-perceived well-being reports (e.g. Mendlowicz and Stein, 2000). According to the World Health Organization, QoL can be defined as ‘an individual’s perception of their position in life in the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards and concerns’ (The WHOQOL Group, 1995: 1403). Researchers agree that QoL represents a multidimensional construct that can be related to different life domains, such as physical, social, environmental and psychological QoL (e.g. Quilty et al., 2003).

Several studies have linked the experience of having a chronic illness with decreased QoL (e.g. Owczarek and Jaworski, 2016; Pinto-Gouveia et al., 2014). A study in a mixed sample of 920 chronic patients, suffering from different chronic diseases (such as cardiovascular, respiratory and endocrine diseases), reported that these individuals presented low levels of QoL (Azevedo et al., 2013). Chronic illnesses can negatively impact one’s daily routines, level of independence and interpersonal relationships and are commonly linked to pain, discomfort and uncertainty about the future, which can prompt feelings of anxiety, helplessness, isolation and despair (Taylor, 2006).

The relationship between chronic illness and self-perceived QoL seems nonetheless to be influenced by numerous aspects beyond the direct impact of physical symptoms (e.g. Trindade et al., 2017a). Particularly, the psychological process that one uses to deal with stress, anxiety or other negative experiences seems to determine the impact those difficulties hold on patients’ QoL and mental health (Graham et al., 2016; Trindade et al., 2020, 2017b).

Experiential avoidance is a maladaptive psychological process that has been indicated as relevant to explain the impact of adverse internal experiences on mental health outcomes. This process is defined as the attempt to escape from unwanted private psychological events, such as unpleasant thoughts, emotions or bodily sensations (Hayes et al., 2006, 2012; Kashdan et al., 2006). The maladaptive nature of experiential avoidance is due to its paradoxical effect (e.g. Kashdan et al., 2006; Wegner, 1994). Attempts to inhibit internal experiences tend to increase their frequency and, at the sample time, restrict the individual to engage in meaningful activities (Kashdan et al., 2006). When individuals engage in experiential avoidance, behaving according to valued goals, that is, engaging in committed action, becomes more difficult (McCracken, 2013; Trindade et al., 2017c). Committed action is defined by behaviours that are consistent with or guided by the individuals’ identified life values (i.e. life directions one chooses to follow). This process comprises activity persistence, even when behaviours that are guided by meaningful values and goals trigger the occurrence of uncomfortable feelings or thoughts (Hayes et al., 2012; McCracken, 2013). This means that when someone engages in actions guided by their chosen values, they are available to accept the painful feelings and thoughts that may emerge in order to move towards a valued path (Hayes et al., 2012).

Different studies documented the harmful effects of experiential avoidance. Trindade and colleagues (2015) demonstrated that the association of symptoms of inflammatory bowel disease with physical and psychological QoL was significantly mediated by experiential avoidance. In addition, Costa and Pinto-Gouveia (2011) also showed that experiential avoidance was positively correlated with anxiety, in a chronic pain sample. However, patients undergoing cardiac rehabilitation who reported lower levels of experiential avoidance found it easier to maintain required lifestyle changes and reported better QoL (Goodwin and Emery, 2016). Furthermore, patients with type 2 diabetes who were educated to apply acceptance and mindfulness skills while dealing with diabetes-related thoughts and feelings reported better diabetes self-care (Gregg et al., 2007).

With this study, we intend to examine experiential avoidance and committed action’s mediating role in the association between anxiety and psychological QoL in college students and to analyse whether these relationships occur in a similar way for students with chronic illness and students without chronic illness. We predict that, students with chronic illness will reveal higher levels of anxiety and experiential avoidance and lower levels of committed action and psychological QoL when compared with students without illness. Furthermore, we expect that anxiety will be linked to higher levels of experiential avoidance and lower levels of committed action and psychological QoL, and that experiential avoidance and committed action will mediate the link between anxiety and psychological QoL for both samples.

Material and method

Participants

This study comprised two samples of college students, aged between 18 and 35 years. The healthy sample (Sample 1) was composed of 232 (35 males and 197 females) participants, with a mean age of 21.89 (standard deviation (SD) = 3.03) and a mean of 14.56 (SD = 1.92) years of education. The chronic illness sample (Sample 2) was composed of 115 college students with a diagnosis of chronic disease (19 males and 96 females), with a mean age of 24.27 (SD = 4.54) and a mean of 15.08 (SD = 1.81) completed years of education. The most common diagnoses of chronic illnesses from Sample 2 were as follows: asthma (22.6%), Crohn’s disease (9.6%), psoriasis (9.6%) and celiac disease (7.8%) (Table 1). Thirty per cent of the diseases were gastrointestinal, 30 per cent were respiratory, 13 per cent were skin conditions, 13 per cent were nervous system diseases and 12 per cent were endocrine diseases. Among chronically ill students, 18 (15%) were diagnosed with more than one chronic illness. Time since diagnosis varied between 1 month and 24 years, with a mean of 9.20 (SD = 7.42) years. Regarding hospital admissions, 42 participants (36.5%) reported having been hospitalized in the past, while 71 participants (61.7%) had never been admitted to the hospital.

Table 1.

Diseases presented by participants.

Disease	n	%
Asthma	28	24.3
Crohn’s disease	12	10.4
Psoriasis	10	8.7
Coeliac disease Epilepsy	8	7
Ulcerative colitis	7	6.1
Diabetes mellitus type 1 Endometriosis	6	5.2
Eczema Lactose intolerance Multiple sclerosis	4	3.5
Allergic rhinitis Arthritis Hypothyroidism Lupus erythematosus	3	2.3
Chronic gastritis Polycystic ovary syndrome Sickle cell anaemia Sinusitis	2	1.7
Chronic liver disease Chronic kidney disease Congenital muscular dystrophy Dust mite allergy Hormonal disorder Hydrocephalus Irritable bowel syndrome Lordosis Phenylketonuria Plantar hyperhidrosis Sjogren’s syndrome Spina bifida Vertigo	1	0.9

Most participants, from both samples, were single but in a relationship (51.9%) and the majority resided in an urban area (61.4%). There were no statistically significant gender differences between both samples (t(345) = 0.346; p = 0.729). However, there were significant differences between the samples’ age (t(166.062) = −5.084; p < 0.001) and the years of education (t(345) = −2.412; p = 0.016). Chron-ically ill students are older and present more years of education.

Measures

Participants reported demographic (age, completed years of education, and marital status) and medical (if participant presented a chronic illness) data and completed the Portuguese versions of the following questionnaires.

The Depression, Anxiety and Stress Scale–21

The Depression, Anxiety and Stress Scale–21 (DASS-21; Lovibond and Lovibond, 1995; Portuguese version by Pais-Ribeiro et al., 2004) aims at measuring the participant’s level of depression, anxiety and stress. Participants are asked to rate, using a 4-point scale (from 0 = ‘Did not apply to me at all’ to 3 = ‘Applied to me most of the time’), the extent to which they experienced the symptoms described in the items during the past week. This instrument has demonstrated good internal consistencies in the original study (α_DEP = 0.88; α_ANX = 0.82; α_STR = 0.90; Lovibond and Lovibond, 1995), as well as in the Portuguese validation study (α_DEP = 0.85; α_ANX = 0.74; α_STR = 0.81; Pais-Ribeiro et al., 2004). For the purpose of this study, only the anxiety subscale was analysed (e.g. ‘I experienced trembling (e.g. in the hands)’; ‘I was worried about situations in which I might panic and make a fool of myself’; and ‘I felt scared without any good reason’). This subscale revealed a good level of internal consistency both in the healthy sample (α_ANX = 0.75) and in the chronically ill sample (α_ANX = 0.86).

The Acceptance and Action Questionnaire–II

The Acceptance and Action Questionnaire–II (AAQ-II; Bond et al., 2011; Portuguese version by Pinto-Gouveia et al., 2012) is a seven-item scale designed to assess experiential avoidance (e.g. ‘I worry about not being able to control my worries and feelings’; ‘My painful experiences and memories make it difficult for me to live a life that I would value’). Participants are asked to rate the extent to which each statement is true to them using a 7-point scale (from 1 = ‘Never true’ to 7 = ‘Always true’). Higher scores reflect greater experiential avoidance. The scale presented high internal consistencies, with a Cronbach’s alpha mean of 0.84 in the original study (Bond et al., 2011) and an alpha of 0.90 in the Portuguese study (Pinto-Gouveia et al., 2012). In this study, the AAQ-II presented a Cronbach’s alpha of 0.90 and of 0.91 in the healthy and chronically ill samples, respectively.

The Committed Action Questionnaire–8

The Committed Action Questionnaire–8 (CAQ-8; McCracken et al., 2014; Portuguese version by Trindade et al., 2017c) is an eight-item self-report measure of committed action. Participants were asked to indicate each item’s accuracy (e.g. ‘My painful experiences and memories make it difficult for me to live a life that I would value’; ‘I am able to follow my long terms plans including times when progress is slow’), concerning their ability to maintain or change their goal-directed behaviour, on a 7-point scale (ranging from 0 = ‘Never true’ to 6 = ‘Always true’). Higher scores reflect higher levels of committed action. The original version of the CAQ-8 presented excellent internal consistency (α = 0.96; McCracken et al., 2014). The Portuguese version of CAQ-8 also presented good psychometric properties (with αs between 0.79 and 0.86 in clinical and healthy samples, respectively; Trindade et al., 2017c). In this study, Cronbach’s alpha was 0.82 and 0.81 for the healthy and chronically ill samples, respectively.

The World Health Organization Brief Quality-of-Life Assessment Scale

The World Health Organization Brief Quality-of-Life Assessment Scale (WHOQOL-BREF; The WHOQOL Group, 1998; Portuguese version by Canavarro et al., 2007) is a 26-item short form of the subjective QoL assessment instrument. This measure comprises four domains: physical, psychological, social relationships and environment. Furthermore, the scale includes two additional items that evaluate one’s overall perception of QoL. Respondents were asked to rate 26 items, regarding their perception of their QoL, on a 5-point scale (from 1 = ‘extreme dissatisfaction’ to 5 = ‘extreme satisfaction’), with higher scores indicating higher levels of self-perceived QoL. WHOQOL-BREF has presented adequate criterion and content validity, internal consistency and test–retest reliability, both in its original version (with Cronbach’s alpha values ranging from 0.66 to 0.84; The WHOQOL Group, 1994) and in the Portuguese version (with Cronbach’s alpha values ranging from 0.67 to 0.87; Canavarro et al., 2007). In this study, this measure’s dimensions also presented adequate internal consistencies for both samples (with Cronbach’s alpha values between 0.61 and 0.80).

Procedures

This study was approved by the Ethics Committee of the Faculty of Psychology and Education Sciences of the University of Coimbra prior to sample recruitment. The study was advertised through a social network (Facebook), through pages of student associations and chronic patients associations. Potential participants were informed about inclusion criteria, the confidential nature and purpose of collected data and the estimated time of completion of the self-report questionnaires. A link redirected individuals to an online survey that included demographic and clinical questions and the self-report measures of interest. All respondents signed an informed consent before completion of the survey.

Inclusion criteria for participation in the study were as follows: (a) age ⩾ 18, (b) college student, (c) native speaker of Portuguese and (d) absence of psychiatric condition (self-reported by participants: ‘Are you currently diagnosed with a mental illness?’).

A total of 355 students completed online survey. Participants who did not meet the inclusion criteria were then excluded from the analyses: seven participants reported psychiatric disorders, namely, bipolar disorder and depression, and one participant reported visual impairment. Participants were then divided into two samples: participants who reported no diagnosis of a chronic illness were assigned to Sample 1, and Sample 2 comprised participants who reported a previous clinical diagnosis of a chronic illness.

Analytic strategy

Preliminary data analyses, t-tests and correlation analyses were conducted using IBM SPSS Statistics 23.0 (SPSS IBM; Chicago, IL) and path analyses were performed using AMOS software (v. 23.0; Arbuckle, 2014).

Preliminary data analyses were conducted to examine the adequacy of the data for further analysis. Pearson’s correlation coefficients were performed to explore the associations between study variables (Cohen et al., 2003).

Path analyses, a form of structural equation modelling (SEM), were conducted to examine the mediating effect of experiential avoidance and committed action in the relationship between anxiety and psychological QoL. This statistical methodology allows the examination of structural relationships and simultaneously analyses direct and indirect paths (Schumacker and Lomax, 2004). In order to estimate model path coefficients and to compute fit statistics, the maximum likelihood method was used. The following goodness-of-fit indices were used to analyse the adjustment of the model to empirical data: chi-square (χ²; with a recommended small (non-significant) value; Hair et al., 2010), the comparative fit index (CFI) and the Tucker–Lewis Index (TLI), with values >0.95 suggesting a very good fit (Hu and Bentler, 1999; Kline, 2005) and the root mean square error of approximation (RMSEA) with a 90% confidence interval (CI; when ⩽0.05 indicates a good fit to empirical data; Kline, 2005).

To test mediating effects, the bootstrap procedure (with 5000 samples) was used to create 95% bias-corrected CIs around the standardized estimates of total, direct and indirect effects. The mediating effect is considered statistically significant (p < 0.05); zero is not included in the interval between the lower and the upper bounds of the 95% bias-corrected CI (Kline, 2005).

Results

Preliminary data analyses

The assumptions of normality, linearity homoscedasticity, independence of errors, and multicollinearity and singularity were confirmed through the analysis of skewness and kurtosis values of the distribution of variables in this study (Field, 2004). Skewness values ranged from −0.41 (physical dimension of the WHOQOL) to 1.53 (anxiety), while kurtosis values ranged from −0.45 (experiential avoidance) to 2.76 (anxiety). Results, therefore, indicated the absence of severe violation of normality (|Sk| < 3 and|Ku| < 8; Kline, 2005).

Descriptive analyses and correlations

Descriptive analyses (Table 2) showed that the differences regarding anxiety, experiential avoidance, social, physical, psychological and environmental QoL levels between the two samples were statistically significant. In general, chronically ill students presented higher levels of anxiety and experiential avoidance and lower levels of social, physical and psychological QoL. However, committed action levels reported by healthy students were not significantly different from the ones reported by chronically ill students (p > 0.05).

Table 2.

Means (M) and standard deviations (SD) on self-report measures (N = 347).

	Healthy group(n = 232)		Chronic illness group(n = 115)		Test for differences
	M	SD	M	SD	t-value	p-value
1. Anxiety	3.60	3.42	4.95	4.96	−2.615	0.010
2. Experiential avoidance	22.22	8.39	24.64	8.96	−2.476	0.014
3. Committed action	31.83	6.96	31.01	7.32	1.020	0.309
4. Social QoL	68.10	18.04	59.57	22.52	3.541	<0.001
5. Environmental QoL	69.79	13.20	64.29	15.23	3.464	<0.001
6. Physical QoL	72.28	13.87	62.98	16.87	5.113	<0.001
7. Psychological QoL	63.94	13.22	59.57	15.89	2.708	0.007

QoL: quality of life.

Results from correlation analyses (Table 3) demonstrated that, in both groups, anxiety was negatively associated with committed action, social, environmental, physical and psychological QoL, as well as moderately and positively linked with experiential avoidance. Moreover, in both samples, experiential avoidance presented a negative association with a strong magnitude with social, environmental, physical and psychological QoL and committed action. Committed action was positively correlated with all QoL dimensions. Finally, social, physical and psychological QoL presented moderate and positive associations with each other in both groups.

Table 3.

Intercorrelation scores on study variables.

	1	2	3	4	5	6	7	8
1. Age	1	0.19 *	-0.06	0.14	0.08	–0.14	–0.12	0.06
2. Anxiety	−0.18**	1	0.57 ***	–0.39 ***	–0.22 *	–0.28*	–0.58 ***	–0.42 ***
3. Experiential avoidance	−0.10	0.52**	1	–0.54 ***	–0.46 ***	–0.38 ***	–0.57 ***	–0.63 ***
4. Committed action	0.10	−0.19**	−0.43**	1	0.37 ***	0.25 **	0.43 ***	0.67 ***
5. Social QoL	0.11	−0.22**	−0.39**	0.18**	1	0.38 ***	0.33 ***	0.54 ***
6. Environmental QoL	0.01	−0.17**	−0.34***	0.26***	0.37***	1	0.50 ***	0.47 ***
7. Physical QoL	0.10	−0.32**	−0.43**	0.38**	0.30**	0.58***	1	0.58 ***
8. Psychological QoL	0.15*	−0.43**	−0.65**	0.51**	0.47**	0.45***	0.54**	1

QoL: quality of life.

Results from Sample 1 (n = 232) are presented in the bottom side of the table and results from Sample 2 (n = 115) are presented in bold in the upper side of the table.

p < 0.05; **p < 0.01; ***p < 0.001.

Path analysis

A path analysis was performed to examine the role played by experiential avoidance and committed action in the association between anxiety and psychological QoL in both healthy students and students with a diagnosis of chronic illness.

The model (Figure 1) was tested through a fully saturated model (i.e. zero degrees of freedom), consisting of 16 parameters. Results indicated that the direct effect of anxiety on committed action (b_{DASS-21_Anxiety} = −0.06; SEb = 0.09; Z = −0.60, p = 0.550) was not significant. This non-significant path was thus eliminated and the model was readjusted and retested.

Figure 1.

Final path model.

The final model presented an excellent fit to the empirical data, with a non-significant chi-square (χ²(4) = 5.772; p = 0.217) and the following goodness-of-fit indices (CFI = 1.00; TLI = 0.99; RMSEA = 0.04; p = 0.575; CI = 0.00–0.10; Kline, 2005).

This model explained 29 per cent of experiential avoidance, 22 per cent of committed action and 52 per cent of psychological QoL. Furthermore, anxiety presented a significant direct effect of 0.54 on experiential avoidance (b_{DASS-21_Anxiety} = 1.16; SEb = 0.10; Z = 11.97; p < 0.001) and a direct effect of −0.11 on psychological QoL (b_{DASS-21_Anxiety} = −0.39; SEb = 0.16; Z = −2.48; p < 0.05). It was also verified that experiential avoidance had a significant direct effect of −0.47 on committed action (b_AAQ-II = −0.39; SEb = 0.04; Z = −9.93; p < 0.001) and a direct effect of −0.43 on psychological QoL (b_AAQ-II = −0.71; SEb = 0.08; Z = −8.82; p < 0.001). In turn, committed action had a direct effect of 0.34 on psychological QoL (b_CAQ-8 = 0.68; SEb = 0.09; Z = 8.02; p < 0.001).

The analysis of indirect effects demonstrated that anxiety had an indirect effect of −0.25 (CI = −0.32 to −0.19; p < 0.001) on committed action through experiential avoidance. Also, anxiety presented an indirect effect of −0.32 on psychological QoL (CI = −0.39 to −0.25; p < 0.001) through the effects of experiential avoidance and committed action. Finally, results also demonstrated that experiential avoidance had an indirect effect of −0.16 on psychological QoL (CI = −0.21 to −0.11; p < 0.001) explained through committed action.

Finally, the invariance of this model was examined across the healthy students sample and the chronic students sample through a multigroup analysis. Results from the chi-square difference test between the unconstrained ( $χ_{(8)}^{2} = 13.091$ ; p < 0.109) and the constrained ( $χ_{(13)}^{2} = 21.955$ ; p = 0.056) models revealed that the model was invariant across the two groups ( $χ_{diff (5)}^{2} = 8.864$ ; p = 0.115), that is, the samples did not present significant differences at the model level.

Discussion and conclusion

Literature has highlighted the association between high levels of anxiety and poorer QoL (e.g. Quilty et al., 2003). Despite the direct impact of anxiety on self-perceived psychological well-being, there is evidence that this relationship may be explained by experiential avoidance and lack of committed action. Many studies have recently showed the mediating effect of experiential avoidance on QoL among chronic patients (Owczarek and Jaworski, 2016; Pinto-Gouveia et al., 2014; Trindade et al., 2015). Thus, given that empirical evidence has demonstrated that high rates of anxiety are present between young adult university students (Andrews and Wilding, 2004; Bayram and Bilgel, 2008) this study intended to clarify the mediating role of experiential avoidance and committed action in the relationship between anxiety and psychological QoL in a sample of healthy students and a sample of students suffering from chronic illness.

In accordance with our proposed hypotheses and prior research, chronically ill students reported higher anxiety and experiential avoidance levels in comparison with students without chronic illness. Psychological QoL levels shown by the chronic illness group were lower than the ones found in the healthy sample. Given that chronically ill students also reported higher levels of experiential avoidance, it was expected that lower committed action levels would be found in participants with chronic illness (Kashdan et al., 2006; McCracken, 2013). However, results showed that committed action levels reported by chronically ill students were not significantly different from the committed action scores presented by the healthy sample. It can be possible that students with chronic illness are more aware of their efforts for committed action in adverse times, as measured by the CAQ-8 (e.g. ‘I am able to follow my long terms plans including times when progress is slow’; ‘If I feel distressed or discouraged, I let my commitments slide’), thus misleadingly scoring on this outcome with similar levels as students without illness. It can also be hypothesized that the groups differ in experiential avoidance and not in committed action levels because the chronic illness group may tend to engage more in forms of experiential avoidance directly related to internal experiences (e.g. attempts at suppressing physical sensations), that do not necessarily influence outward behaviours, than the group without illness tends to. In this sense, both groups may engage in similar levels of forms of experiential avoidance that directly influence committed attitudes and behaviours and present differences in the forms of experiential avoidance that are related to the management of difficult sensations such as pain or illness symptomatology.

Results from the correlation analyses showed that, in both groups, anxiety was negatively associated with engagement in committed action and psychological QoL and positively linked with experiential avoidance. Moreover, experiential avoidance presented a negative relationship with both committed action and psychological QoL, which are positively correlated with each other. These results are in line with previous literature suggesting that experiential avoidance is a maladaptive psychological process (Hayes et al., 2006), and linked to lack of committed action, and to lower levels of QoL (e.g. Trindade et al., 2017c).

In order to better explore these outcomes, path analyses were performed to analyse the mediating effect of experiential avoidance and committed action on the association between anxiety and psychological QoL. Path analysis results revealed that the tested model presented an excellent fit to the empirical data and explained 29 per cent of experiential avoidance, 22 per cent of committed action and 52 per cent of the variance of psychological QoL.

Findings from the model suggested that the effect of anxiety on psychological QoL was mediated by the mechanisms of experiential avoidance and committed action. It was demonstrated that anxiety led to higher levels of experiential avoidance which in turn predicted difficulties in engaging in meaningful and committed activities. These processes significantly explained the negative impact of anxiety on psychological QoL, both in healthy and chronically ill college students. A multigroup analysis revealed that the model was invariant across the healthy sample and the sample of chronic patients, meaning that these relationships seem to occur in a similar way for both students with and without chronic illness. These findings go in line with previous literature by highlighting that when individuals do not accept unpleasant internal experiences (such as anxiety), the ongoing management of these private events may lead putting on hold meaningful activities (Hayes et al., 2012; McCracken, 2013). For instance, when facing heightened anxiety levels, one might respond to that experience by attempting to control further distress by avoiding certain situations that might prompt physical pain, anxiety or shame. This lower tolerance towards the experience of negative thoughts, feelings and sensations may restrict individuals from pursuing personally valued life directions, progressively decreasing their functioning and QoL.

These findings should be interpreted with caution as this study presents some limitations. The main limitation of this study lies on its transversal design, meaning it is not possible to draw causal interpretations from the presented results. Therefore, it would be interesting that longitudinal or experimental designs would aim to test the same hypotheses for a better understanding of this study’s findings. Second, this study’s samples are composed solely of college students, and the generalization to the general population is not possible. Also, participants were recruited through Facebook groups which may have restricted the collection of a representative sample of college students and precluded the collection of clinical data provided by a clinician and the conduction of screening interviews to assess inclusion criteria. Future studies should thus use other recruitment (e.g. in hospitals) and assessment (e.g. interviews to assess, for example, anxiety levels) methodologies. Finally, given that the chronic illness sample presented high heterogeneity regarding diagnoses (with conditions that may have different severities and impact patients’ health and QoL), it seems important for future studies to control illness severity and impact. Finally, it is also important to note that the studied samples of college students presented considerably different sizes (possibly due to the increased difficulty in collecting participants with chronic illness) and age means, which may impose a significant limitation in the interpretation of results. Future research should aim to compare homogeneous samples to allow more solid conclusions.

The current findings seem to offer new contributions concerning the mediating effect of experiential avoidance and committed action on the relationship between anxiety and psychological QoL on college students. Our results point out that the attempt to control and avoid unpleasant thoughts, feelings and sensations seems to be a maladaptive strategy to deal with anxiety as it might lead to difficulties in engaging in valued actions, which altogether diminish psychological QoL. Finally, this study seems to highlight the pertinence of interventions that focus on the promotion of acceptance and committed action (such as acceptance and commitment therapy; Hayes et al., 2012) in college students with or without chronic illness.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: Research by Inês A. Trindade was supported by a PhD Grant (No. SFRH/BD/101906/2014) sponsored by FCT (Portuguese Foundation for Science and Technology).

ORCID iD

Inês A Trindade

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