Self-compassion and health-related quality of life in individuals with endometriosis

Objective: International research highlights the detrimental impact of endometriosis on health-related quality of life (HRQoL), yet few studies have examined positive resources such as self-compassion and resilience as correlates. This cross-sectional study aimed to examine the relationship between self-compassion and HRQoL in individuals with endometriosis in Aotearoa New Zealand. Resilience and perceived symptom severity were examined as potential mediators.

and measures:  Six hundred and three individuals with endometriosis completed an online questionnaire measuring demographic and endometriosis-related information, endometriosis symptoms (number and severity), HRQoL, self-compassion and resilience.

In line with international research, the current sample reported significant impairment in all aspects of HRQoL. As expected, those with higher levels of self-compassion reported less impairment in HRQoL, and this relationship was partially mediated by perceived symptom severity (all aspects of HRQoL). Resilience mediated the relationship between self-compassion and two aspects of HRQoL (emotional wellbeing and control/powerlessness).

These findings confirm that HRQoL is significantly impaired in individuals with endometriosis in Aotearoa New Zealand and point to the potential role of self-compassion and resilience as protective factors in encouraging positive coping styles to manage symptoms and maintain high HRQoL. Interventions targeting self-compassion may be a promising tool to improve wellbeing in individuals with endometriosis.

Endometriosis is a chronic, gynaecological condition where tissue that is similar to the lining of the uterus (endometrium) is found in places outside the uterus (Kennedy et  al., 2005). It is a common condition estimated to affect between 5% and 11% of reproductive-aged females and those assigned female at birth (Adamson et  al., 2010; © 2024 t he a uthor(s). Published by Informa UK limited, trading as taylor & Francis group CONTACT chelsea M. skinner [email protected] s chool of Psychology, speech and hearing, University of c anterbury, Private Bag 4800, christchurch 8140, New Zealand. supplemental data for this article can be accessed online at https://doi.org/10.1080/08870446.2024.2325506. https://doi.org/10.1080/08870446.2024.2325506 t his is an o pen a ccess article distributed under the terms of the c reative c ommons a ttribution-Nonc ommercial-NoDerivatives license (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way. t he terms on which this article has been published allow the posting of the a ccepted Manuscript in a repository by the author(s) or with their consent. ARTICLE HISTORY Received 20 November 2023 Accepted 26 February 2024

Endometriosis; quality of life; self-compassion; resilience; symptom severity 1480 C. M. SKINNER AND R. G. KUIJER Rowlands et  al., 2021). Common symptoms include pain with periods (dysmenorrhoea), chronic non-menstrual pelvic pain, painful intercourse (dyspareunia), abnormal bleed - ing between cycles, bowel and bladder problems, fatigue, and infertility (Kennedy et  al., 2005). Although these symptoms are frequently reported, there is considerable variability in symptom presentation, with some individuals experiencing no symptoms (asymptomatic) while others report multiple and severely debilitating symptoms (Vercellini et  al., 2007). There is currently no cure for endometriosis and management focuses on symptom relief with varying degrees of success (Becker et  al., 2017; Ferrero et  al., 2018). The negative impact of endometriosis on psychological wellbeing and health-related quality of life (HRQoL) has been well-documented, with negative effects found on all aspects of quality of life, including physical, psychological, occupational, and inter - personal functioning (e.g. Culley et  al., 2013; De Graaff et  al., 2013; Facchin et  al., 2015; Soliman et  al., 2017, 2020; Tewhaiti-Smith et  al., 2022). The extent to which HRQoL is impaired depends on several factors, including the number of symptoms experienced and the severity of those symptoms. For example, in two large cross-sectional samples, Soliman et  al. ( 2017, 2020) found that HRQoL scores decreased as endometriosis symptom severity and the number of symptoms reported increased. Moreover, a study by Facchin et  al. ( 2015) found that women with endometriosis who experienced pelvic pain had significantly poorer quality of life compared to those with asymptomatic endometriosis. A recent study conducted in Aotearoa New Zealand found that the experience of chronic pelvic pain symptoms, regardless of diagnosis (endometriosis, other underlying condition, no formal diagnosis), severely impacted quality of life in the areas of work, education, and relationships (Tewhaiti-Smith et  al., 2022). Although symptom severity and the number of symptoms reported are clearly important predictors of HRQoL, it is also clear that some individuals are better able to maintain high levels of HRQoL than others. Understanding how HRQoL and psy - chological wellbeing may be improved in individuals with endometriosis is crucial as medical interventions alone are often inadequate. A growing evidence base suggests that self-compassion may be an important resource in coping with chronic illness (Sirois & Rowse, 2016). Self-compassion consists of six components: self-kindness versus self-judgment (being kind, non-judgemental and understanding towards oneself in difficult times), mindfulness versus overidentification (being in touch with difficult experiences in a mindful and accepting manner) and common humanity versus iso - lation (recognising that struggles and personal shortcomings are common to all people) that combine to create a self-compassionate frame of mind (Neff, 2003a, 2003b, 2023). Self-compassion is generally operationalised as a stable, trait-like con - struct (Medvedev et  al., 2021; Neff, 2003a, 2003b, 2023), but can also be raised via interventions (Kılıç et  al., 2021; Neff & Germer, 2013; Neff, 2023). Self-compassion has been consistently related to higher psychological wellbeing in the general population (Marsh et  al., 2018; Zessin et  al., 2015). Self-compassion has also been associated with improved outcomes in people with chronic health conditions, including increased HRQoL (e.g. Nery-Hurwit et  al., 2018; Pinto-Gouveia et  al., 2014), higher psychological wellbeing (e.g. Prentice et  al., 2021), and less pain-related disability (e.g. Edwards et  al., 2019). Research examining self-compassion in individuals with endometriosis is scarce. The few studies that have been done show that higher self-compassion is PSyCHoL oGy & HEALTH 1481 related to lower levels of depression, anxiety, endometriosis-related distress, and fewer endometriosis-related symptoms (Van Niekerk et  al., 2022), greater HRQoL in the domain of emotional wellbeing (Van Niekerk et  al., 2023), and less sexual distress (Sullivan-Myers et  al., 2023). There are several ways in which self-compassion may be related to improved psy - chological wellbeing and HRQoL. one mechanism may be through increased resilience. Resilience has been defined as the ability to bounce back from stressful events (Smith et  al., 2008) and has been found to be associated with better HRQoL and psycholog - ical wellbeing in individuals with chronic health conditions, including endometriosis (e.g. Lubián-López et  al., 2021; Nery-Hurwit et  al., 2018; Romaniuk & oniszczenko, 2023). When considered together, several studies have found that self-compassion and resilience are both uniquely associated with improved physical and mental health (Asensio-Martínez et  al., 2019 ; Bag et  al., 2022 ). Individuals who are more self-compassionate tend to use more adaptive coping skills, including emotion-focused strategies such as acceptance and positive reframing and problem-focused coping strategies such as planning and seeking instrumental support (Ewert et  al., 2021; Sirois et  al., 2015) and are better able to regulate their emotions (Terry & Leary, 2011), all of which may promote resilience (Bluth et  al., 2018). For example, recognising that others have gone through similar experiences and that one is not alone in suffering (common humanity vs. isolation dimension of self-compassion) may make it easier for an individual with endometriosis to seek support which in turn may promote resilience. In a study among individuals with multiple sclerosis, Nery-Hurwit and col - leagues (2018) found that resilience mediated the relationship between self-compassion and HRQoL. Another way through which self-compassion may be related to HRQoL is through perceived severity of symptoms. In research with individuals with chronic pain, low self-compassion has been associated with greater pain-related catastrophising and fear and lower pain acceptance (Edwards et  al., 2019; Wren et  al., 2012). These findings are especially relevant since high pain-related catastrophising and anxiety have been found to be important factors related to impairment in HRQoL in individuals with endometriosis (McPeak et  al., 2018; van Aken et  al., 2017). The main aim of the current study was to examine the relationship between self-compassion, resilience, perceived symptom severity, and HRQoL in individuals with endometriosis. Although ample research has shown that self-compassion is related to better HRQoL in chronic illness populations, research investigating self-compassion in endometriosis is lacking. In addition, the mechanisms through which self-compassion may influence HRQoL are not well understood. Based on pre - vious research, we expected that individuals with higher levels of self-compassion would report higher levels of HRQoL, and we expected perceived symptom severity and resilience to mediate this relationship. Research on HRQoL of individuals with endometriosis in Aotearoa New Zealand is scarce. The only study recently conducted (Tewhaiti-Smith et  al., 2022) did not use a validated instrument to measure HRQoL making comparisons with the international literature difficult. Therefore, a secondary aim of the current study was to assess HRQoL with the well-validated Endometriosis Health Profile (EHP)-30 (Jones et  al., 2001) to better understand the impact endometriosis has on individuals in Aotearoa New Zealand. 1482 C. M. SKINNER AND R. G. KUIJER

Participants and procedure The sample consisted of 603 individuals from Aotearoa New Zealand with a self-reported diagnosis of endometriosis. Participants were recruited over a period of one month through Aotearoa New Zealand endometriosis organisations such as Endometriosis New Zealand and Endo Warriors Aotearoa (social media and website) and advertising on social media (Facebook and Instagram) in June 2021. Participation in the study involved completing an online survey. Participants provided informed consent before partaking in the survey. Those who completed the survey were entered into a draw to win one of six 50 NZD supermarket vouchers. Inclusion criteria for the study were: (1) having been diagnosed with endometriosis via laparoscopic surgery or having received such a diagnosis from a medical professional without surgery, (2) aged between 18 and 45 years and (3) living in Aotearoa New Zealand. Seven hundred and fifteen individuals completed the survey. o ne hundred and twelve did not meet the inclusion criteria and were therefore excluded from data analysis ( n = 97 experienced pelvic pain but had not been diagnosed with endometriosis, n = 4 were aged outside the age range, and n = 11 did not live in Aotearoa New Zealand). The study was approved by the University of Canterbury Human Ethics Committee (HEC2021/40). Measures Demographic and endometriosis-related information Gender, age, ethnicity, education, and employment status were measured. Participants could identify with more than one ethnic group in the questionnaire. Following the Ministry of Health’s ethnicity data protocol (Ministry of Health, 2017), participants were assigned into an ethnic group using a hierarchy of prioritisation: (1) Māori, (2) Pacific, (3) Asian, (4) Middle Eastern, Latin American and African, and (5) European (Ministry of Health, 2017). Endometriosis-related information collected included diag - nostic procedure (through laparoscopic surgery or being told by a health professional without surgery), time since diagnosis (in years), and diagnostic delay (measured on a six-point scale ranging from up to 1 to 8+ years ). Endometriosis symptoms: number and severity Participants were asked to indicate whether they were experiencing eight common endometriosis-related symptoms (e.g. pain with periods, bowel problems; see Table 1 for the full list; Kennedy et  al., 2005) and rate the severity of these symptoms (1 = mild, 2 = moderate, 3 = severe, 0 = do not experience/not applicable ). Based on this measure, two scores were generated: a frequency measure (a simple count of the number of symp - toms scoring 1 or higher; range 0–8) and a perceived severity measure (the sum of the severity ratings averaged over the number of symptoms; range 0–3). HRQoL HRQoL was measured with the EHP-30 disease-specific instrument (Jones et  al., 2001), an extensively validated measure of quality of life in those with endometriosis (Bourdel PSyCHoL oGy & HEALTH 1483 et  al., 2019). The core instrument includes 30 items assessing five domains: pain (11 items), control and powerlessness (6 items), emotional wellbeing (6 items), social support (4 items), and self-image (3 items). Items are measured on a five-point scale ranging from 1 ( Never) to 5 ( Always) and are assessed in relation to the past 4 weeks. Examples of questions include ‘During the last 4 weeks, how often because of your endometriosis have you felt unable to cope with the pain?’ and ‘During the last 4 weeks, how often because of your endometriosis have you felt alone?’ . Items are summed to form subscales for each domain and are then standardised on a scale from 0 to 100, where 0 indicates the best possible health status and 100 the worst Table 1. Demographic and endometriosis-related information. Percentage ( M) Frequency ( SD) gender Female 98.5% 594 Male 0.2% 1 g ender diverse 1.35% 8 a ge (years) (18–45) 29.48 6.84 ethnicity e uropean 83.6% 504 Māori 11.9% 72 Pacific 1.2% 7 o thera 3.3% 20 education No qualification 3.0% 18 s econdary school 30.5% 184 Post-school degree 12.8% 77 University degree 49.9% 301 o ther 3.8% 23 employmentb Full time 43.9% 265 Part time 24.2% 146 Unemployed 4.5% 27 s tudent 21.1% 127 homemaker 8.8% 53 s elf-employed 8.1% 49 Unable to work 6.6% 40 Diagnosis t hrough laparoscopy 90.2% 544 o ther 9.8% 59 t ime since diagnosis (years) 6.45 5.51 Diagnostic delay Up to 1 year 12.8% 77 1–2 years 15.1% 91 3–4 years 18.2% 110 5–6 years 16.3% 98 7–8 years 11.3% 68 8+ years 26.4% 159 endometriosis symptoms (% yes) Pain with periods (dysmenorrhea) 97.4% 587 Bowel problems 97.2% 586 Painful intercourse 81.9% 494 sub-fertility/infertility 37.0% 223 t iredness/low energy 96.2% 580 a bnormal menstrual bleeding 82.3% 496 Pain in other areas, e.g. lower back 93.0% 567 Pain at other times, e.g. ovulation 94.4% 569 Number of symptoms (0–8) 6.80 1.02 Perceived severity of symptoms (0–3) 2.01 0.42 aa sian, Middle eastern, latin a merican and a frican combined. bPercentages do not add up to one hundred and total frequencies exceed 603 due to participants being able to tick more than one response. 1484 C. M. SKINNER AND R. G. KUIJER possible health status. Cronbach’s alpha for each of the subscales in the current study was as follows: pain .95, control and powerlessness .92, emotional wellbeing .89, social support .88, and self-image .89. A summary score (EHP-30 Core summed scale) can also be calculated by producing one overall score combining the five domains into one single score, again ranging from 0 to 100. The core instrument can be expanded with six modules, measuring quality of life dimensions that may not be relevant to all participants with endometriosis. The modules are work life, sexual intercourse, relationship with children, relationship with health professionals, treatment, and infertility. The modules are described in the Supplementary material . Self-compassion The Self-Compassion Scale-Short Form (Raes et  al., 2011 ) was used to measure self-compassion. This 12-item scale is a shortened version of the 26-item Self-Compassion Scale (Neff, 2003a). The scale correlates .97 with the full scale (Raes et  al., 2011) and is a validated and reliable measure of self-compassion with excel - lent internal consistency and strong temporal stability (Medvedev et  al., 2021; Raes et al., 2011). Items are rated on a five-point scale ranging from 1 ( Almost Never ) to 5 ( Almost Always). Examples of statements include ‘I try to be understanding and patient towards those aspects of my personality I don’t like’ (self-kindness), ‘When something upsets me, I try and keep my emotions in balance’ (mindfulness) and ‘I try to see my failings as part of the human condition’ (common humanity). Negatively worded items were reversed scored so that higher scores indicate higher levels of self-compassion on all items. The 12 items were summed and then averaged to form a scale. Cronbach’s alpha was .85 in the current study. Resilience The Brief Resilience Scale (Smith et  al., 2008) was used to assess an individual’s ability to bounce back or recover from stress. The scale includes six brief statements rated on a five-point scale ranging from 1 ( Strongly Disagree ) to 5 ( Strongly Agree ). Example items include ‘I tend to bounce back quickly after hard times’ and ‘I take a long time to get over setbacks in my life’ . Negatively worded items were reversed scored. The six items were summed and then averaged to form a scale. Higher total scores reflect greater resilience. The scale is a well-validated measure of resilience that is widely used and consistently demonstrates good to excellent reliability (McKay et  al., 2021; Sánchez et  al., 2021; Smith et  al., 2008; Windle et  al., 2011). Cronbach’s alpha was .87 in the current study. Analyses Prior to analysis, normality assumptions were checked for each variable. Number of symptoms, years since diagnosis, and diagnostic delay were skewed and/or had high kurtosis and were therefore log transformed. Following descriptive and correlational analyses, the PR oCESS macro for SPSS by Hayes ( 2018) was used to run mediation PSyCHoL oGy & HEALTH 1485 analyses with 10,000 bias-corrected bootstrap samples. Separate analyses were run for the EHP-30 Core summed scale and each of the Core subscales (i.e. pain, control and powerlessness, emotional wellbeing, social support, self-image) as dependent variables. In these analyses, self-compassion was the predictor variable, and perceived symptom severity and resilience, the mediator variables (Model 4 in PR oCESS). Age, level of education, and number of symptoms reported were consistently and signifi - cantly related to the EHP-30 Core subscales and Core summed scale (see Table 2 ) and were therefore included as covariates in the analyses. Although number of symp - toms reported and perceived severity of symptoms were highly correlated ( r = .73), none of the variance inflation factors in the multiple regression analyses exceeded 2.5. Analyses with the EHP-30 Modules are reported in the Supplementary Material .

Descriptive analyses Demographic and endometriosis-related information is presented in Table 1. Participants in the study predominantly identified as female (98.5%), were of European ethnicity (83.6%), and were on average 29 years old ( SD = 6.8). The majority was educated beyond secondary school level (62.7%) and most were employed, either full-time Table 2. c orrelations and descriptive statistics for the key variables in the study. 1 2 3 4 5 6 7 8 9 1. Pain 1.00 2. c ontrol and powerlessness .79*** 1.00 3. emotional wellbeing .66*** .69*** 1.00 4. s ocial support .61*** .72*** .66*** 1.00 5. s elf-image .56*** .61*** .58*** .69*** 1.00 6. ehP-30 c ore sum .83*** .89*** .83*** .87*** .83*** 1.00 7. s elf-compassion −.22*** −.30*** −.46*** −.38*** −.34*** −.40*** 1.00 8. Resilience −.17*** −.26*** −.36*** −.24*** −.22*** −.29*** .53*** 1.00 9. s ymptom severity .47*** .43*** .39*** .37*** .39*** .48*** −.16** −.13** 1.00 10 Number of symptoms .21*** .20*** .22*** .24*** .25*** .27** −.08 −.02 .73*** 11. a ge −.28*** −.23*** −.23*** −.17*** −.17*** −.25*** .19*** .14*** −.08 12. e ducation −.27*** −.23*** −.29*** −.23*** −.18*** −.28*** .17*** .21*** −.15** 13. e thnicity .12** .07 .09* .11** .14*** .12** −.02 −.01 .07 14. Diagnosis .05 .01 .05 .03 .01 .03 .05 −.03 −.02 15. y ears since diagnosis −.12** −.17*** −.07 −.12** −.13*** −.14*** .07 .07 .05 16. Diagnostic delay .06 .11** −.01 .13*** .12** .10* −.01 −.04 .12** M 50.23 61.45 49.67 58.73 62.23 56.49 2.74 3.02 2.01 SD 20.69 24.38 21.08 25.79 27.22 20.21 0.61 0.79 0.42 Range 0–100 0–100 0–100 0–100 0–100 0–100 1–5 1–5 0–3 N 601 602 602 601 601 599 602 602 603 Note: ethnicity: 1 = e uropean, 2 = non-e uropean; Diagnosis: 1 = laparoscopy, 2 = other. ehP-30 c ore sum = summary score of the five ehP-30 c ore subscales (pain, control and powerlessness, emotional wellbeing, social support, self-image) combined. *p < .05. **p < .01. ***p < .001. 1486 C. M. SKINNER AND R. G. KUIJER (43.9%) or part-time (24.2%). The vast majority of participants were diagnosed via laparoscopic surgery (90.2%) and the average time since diagnosis was 6.5 years (SD = 5.5). More than half of the sample (54.0%) waited more than 5 years to receive a diagnosis. Participants reported experiencing on average 6.8 (out of 8; SD = 1.02) common endometriosis symptoms with some of the symptoms reported by nearly all individuals in the sample (e.g. pain with periods, bowel problems, tiredness/low energy, see Table 1 ). on average, participants reported the symptoms to be of mod - erate severity ( M = 2.01, SD = 0.42). Table 2 displays the correlations and descriptive statistics for the key variables in the study. Mean scores on the EHP-Core subscales ranged from 49.67 to 62.23 with least impairment reported on the emotional wellbeing subscale and highest impair - ment on the self-image subscale. Mean scores on the EHP-Modules ranged from 41.57 to 77.55 ( Supplementary Material ) with least impairment reported on the relationship with children scale and most impairment on the infertility scale. For all subscales (Core and Modules), the average scores exceeded 40 indicating at least moderate impairment on all subscales. Participants with higher levels of self-compassion and resilience reported significantly less impairment on the EHP-30 Core summed scale and each of the Core subscales. They also perceived their symptoms to be less severe, although these correlations were small. Participants who reported experiencing more symptoms and who perceived those symptoms to be more severe reported higher levels of impairment on quality of life (EHP-30 Core summed scale and subscales). older participants and participants with higher education reported less impairment on quality of life (EHP-30 Core summed scale and subscales). They also reported higher levels of self-compassion and resilience. There were a few significant but small correlations (all <.18) between ethnicity, years since diagnosis, and quality of life, with non-European participants and participants who had been diagnosed a shorter time ago reporting more impairment on the EHP-30 Core summed scale and some of the Core subscales. Finally, longer diagnostic delay was significantly related to higher impairment on some of the Core subscales and higher perceived severity of symptoms although these correlations were very small (all <.14). Correlations with the EHP-Modules showed a similar pattern although not all correlations were significant due to reduced power (see Supplementary Material ). Mediation analyses Table 3 presents the findings of the mediation analyses for the EHP-30 Core subscales and summed scale. In each analysis, age, education, and number of symptoms reported were controlled for. Self-compassion was found to be a significant predictor of per - ceived severity of symptoms and resilience (X → M in Table 3 ). Self-compassion and the covariates explained 55% of the variance in perceived severity of symptoms and 29% of the variance in resilience. Perceived severity of symptoms mediated the rela - tionship between self-compassion and the EHP-30 Core summed scale and all five subscales (i.e. none of the confidence intervals for the indirect effect of perceived severity of symptoms included zero, and the M → y paths for severity of symptoms were all significant). Resilience mediated the relationship between self-compassion and the subscales control and powerlessness and emotional wellbeing (i.e. the PSyCHoL oGy & HEALTH 1487 Table 3. Mediation analyses of self-compassion and ehP-30 c ore subscales and ehP-30 c ore summed scale. total effect Direct effect Indirect effect b 95% cI b 95% cI b 95% cI X → M M → y ehP-30 c ore sum −10.67*** [−12.99, −8.34] −8.56*** [−11.04, −6.08] total −2.11 [−3.58, −0.64] (R2 = .39***) M1 −1.22 [−2.15, −0.35] −0.05** 22.82*** M2 −0.88 [−2.08, 0.32] 0.64*** −1.38 Pain −4.48*** [−7.01, −1.95] −2.89*** [−5.54, −0.24] total −1.59 [−3.24, −0.03] (R2 = .33***) M1 −1.52 [−2.65, −0.49] −0.05** 28.29*** M2 −0.11 [−1.34, 1.20] 0.65*** −0.11 c ontrol and power −9.05*** [−12.05, −6.05] −5.90*** [−9.12, −2.68] total −3.15 [−5.14, −1.31] (R2 = .29***) M1 −1.52 [−2.68, −0.45] −0.05** 28.52*** M2 −1.64 [−3.28, −0.08] 0.65*** −2.52* emotional WB −13.37*** [−15.76, −10.99] −10.47*** [−13.10, −7.83] total −2.91 [−4.50, −1.42] (R2 = .36***) M1 −0.90 [−1.63, −0.27] −0.05** 16.86*** M2 −2.01 [−3.43, −0.71] 0.65*** −3.11** s ocial support −13.58*** [−16.65, −10.50] −12.14*** [−15.60, −8.68] total −1.43 [−3.36, 0.49] (R2 = .26***) M1 −0.99 [−1.85, −0.28] −0.05** 18.67*** M2 −0.44 [−2.22, 1.34] 0.65*** −0.68 s elf-image −12.98*** [−16.28, −9.69] −11.45*** [−15.15, −7.75] total −1.54 [−3.54, 0.48] (R2 = 25***) M1 −1.17 [−2.15, −0.36] −0.05** 22.06*** M2 −0.36 [−2.18, 1.49] 0.65*** −0.56 Note: M1 = perceived symptom severity, M2 = resilience. Number of bootstrap samples = 10,000. a nalyses controlled for age, education and number of symptoms. ehP-30 c ore sum = summary score of the five ehP-30 c ore subscales combined. *p < .05. **p < .01. ***p < .001. 1488 C. M. SKINNER AND R. G. KUIJER confidence intervals for the indirect effect of resilience did not include zero, and the M → y paths for resilience were significant). The amount of variance explained in the dependent variables ranged from 25% (self-image subscale) to 39% (EHP-30 Core summed scale; see Table 3 ). The direct effect of self-compassion on impairment in quality of life (EHP-30 Core summed scale and subscales) remained significant for all dependent variables indicating that mediation was partial rather than full. To illustrate, the mediation model of self-compassion and the EHP-30 Core summed scale is depicted in Figure 1. Participants with higher levels of self-compassion reported less impairment in quality of life and this relationship was partly mediated by per - ceived severity of symptoms: Participants with higher levels of self-compassion per - ceived their symptoms to be less severe which was in turn related to less impairment in quality of life. The findings for the pain, social support, and self-image subscales were similar and are therefore not depicted. For two of the EHP-30 subscales (emotional wellbeing and control and powerless - ness), both perceived symptom severity and resilience mediated the relationship between self-compassion and quality of life. To illustrate, the findings for impairment in emotional wellbeing are presented in Figure 2 : Participants with higher levels of self-compassion perceived their symptoms to be less severe and reported higher levels of resilience which in turn were both related to less impairment in emotional wellbeing. Analyses with the EHP-30 Modules as the dependent variables found similar results: symptom severity was found to be a consistent mediator in the relationship between self-compassion and the EHP-30 Modules, whereas resilience was a significant mediator for one subscale only (treatment module; see Supplementary Material ).

The current study showed that all aspects of HRQoL were impaired in individuals with endometriosis in Aotearoa New Zealand. In line with previous international research, dimensions most strongly impaired were control and powerlessness, sexual intercourse, and fertility (e.g. Chaman-Ara et al., 2017; Chauvet et al., 2017; Sullivan-Myers Figure 1. Mediation model of self-compassion and the ehP-30 c ore summed scale (summary score of the five ehP- c ore subscales combined). a ge, education and number of symptoms were included as covariates. Unstandardised estimates are reported. Unmediated direct effect in parentheses. **p < .01. ***p < .001. PSyCHoL oGy & HEALTH 1489 et  al., 2021). In the current study, high impairment was also found on the self-image dimension. Although this dimension seems to be less impaired in other samples (Chaman-Ara et  al., 2017; Chauvet et  al., 2017; Soliman et  al., 2020), our findings are in line with recent findings from Australia (Sullivan-Myers et  al., 2021, 2023; see Supplementary Material ). The meta-analysis by Chaman-Ara et  al. ( 2017) included papers published between 2001 and 2015. Increased impairment on the self-image dimension may in part reflect changes over time, for example, due to increases in social media use and the associated negative effects on body image (akin to self-image; de Valle et  al., 2021). Another explanation may lie in cultural differences. For example, Rodgers et  al. ( 2011) found that Australian students reported perceiving more peer and media influence regarding physical appearance, higher levels of appearance comparison, and higher levels of internalisation of media ideals than French students. Moreover, a meta-analysis by Saiphoo and Vahedi ( 2019) showed that the link between social media use and body dissatisfaction was stronger in Australia compared to other countries (Saiphoo & Vahedi, 2019). Australia is geographically close to Aotearoa New Zealand and the two countries share similar cultural values which may explain the higher scores on the self-image dimension in the current sample. Participants in the current study also reported high impairment on the treatment dimension (assessing satisfaction with treatment). The latter may reflect the fact that there are numerous barriers to accessing health care and treatment for endometriosis in Aotearoa New Zealand (Tewhaiti-Smith et  al., 2022). The main purpose of the current study was to examine the relationship between self-compassion and HRQoL and shed light on the possible mechanisms through which self-compassion may influence HRQoL in individuals with endometriosis. As predicted, self-compassion was significantly related to quality of life: Individuals with higher levels of self-compassion reported less impairment on all dimensions of HRQoL in the current study. These findings add to the small number of studies that have examined the link between self-compassion and psychological wellbeing in individuals with endometriosis (Sullivan-Myers et  al., 2023; Van Niekerk et  al., 2022, 2023) and support findings from the wider literature that self-compassion may be an important resource for people coping with chronic health conditions (Sirois & Rowse, 2016). Figure 2. Mediation model of self-compassion and the ehP-30 emotional Wellbeing subscale. a ge, education, and number of symptoms were included as covariates. Unstandardised estimates are reported. Unmediated direct effect in parentheses. ** p < .01. ***p < .001. 1490 C. M. SKINNER AND R. G. KUIJER This study suggests that one way through which individuals with high self-compassion may cope better is through rating their symptoms as less severe. Perceived symptom severity was found to partially mediate the relationship between self-compassion and all core aspects of HRQoL (and some of the modules—see Supplementary Material ). Importantly, the number of symptoms reported was con - trolled for in these analyses. These findings are in line with research showing that higher self-compassion is related to less pain catastrophising and higher pain accep - tance in individuals with chronic pain (Edwards et  al., 2019; Wren et  al., 2012). Self-compassion entails being non-judgemental and kind to oneself, and not ove - ridentifying with painful thoughts and experiences (Neff, 2003a, 2023), both of which may reduce pain interference and foster maintenance of quality of life despite expe - riencing pain. Less consistent support was found for resilience as a mediator. Although this study found a strong relationship between self-compassion and resilience as seen in other studies (see Bag et  al., 2022; Bluth et  al., 2018; Nery-Hurwit et  al., 2018) and a sig - nificant relationship between resilience and all aspects of HRQoL in the bivariate analyses (i.e. correlations), resilience was only found to mediate the relationship between self-compassion and two of the core aspects of HRQoL: control/powerlessness and emotional wellbeing. These findings are not in line with Nery-Hurwit et  al ( 2018) who found that resilience mediated the link between self-compassion and a composite HRQoL score (assessing physical, mental and social health) in individuals with multiple sclerosis. However, Nery-Hurwit et  al ( 2018) only examined one mediator (resilience) in isolation. It is possible that perceived severity of symptoms is a more robust medi - ator than resilience. Another possibility is that high resilience is more beneficial for psychological aspects of quality of life than for physical or social aspects. Indeed, research in individuals with chronic conditions other than endometriosis has shown that resilience tends to be more strongly related to the mental health aspects of quality of life than physical aspects (e.g. Harms et  al., 2019; Taylor et al, 2018). Key aspects of resilience are cognitive flexibility (e.g. using more adaptive coping, including positive reappraisal and acceptance and less maladaptive coping, including rumina - tion), and experiencing more positive and less negative affects (Southwick et  al., 2005) all of which may be more strongly related to indicators of emotional wellbeing and feelings of lack of control and powerlessness than other aspects of HRQoL. Future research, preferably longitudinal, is needed to examine whether perceived severity of symptoms is a more robust mediator than resilience in the relation between self-compassion and HRQoL in individuals with endometriosis. In addition, the current study assumed that higher self-compassion was related to lower perceived severity of symptoms due to less pain catastrophising and/or more pain acceptance. However, future research should formally examine these constructs as potential mediators. Another finding worth mentioning is, that in line with previous research, individuals who reported experiencing more symptoms and perceived these symptoms to be more severe, reported higher impairment on HRQoL (EHP-30 Core summed scale and all subscales; e.g. Soliman et  al., 2017, 2020; Tewhaiti-Smith et  al., 2022). This highlights that it is not the presence of endometriosis lesions themselves that impairs quality of life but rather the symptoms experienced due to having endometriosis (Facchin et  al., 2015). PSyCHoL oGy & HEALTH 1491 This study had several strengths. It had a large sample size and used a validated measure of quality of life. It also added more knowledge about individuals living with endometriosis in Aotearoa New Zealand where there is currently little existing research. The study also had some limitations. Firstly, the sample was recruited via social media platforms which may have introduced selection bias. Individuals experiencing more severe endometriosis symptomatology may be more likely to seek information on the internet and follow endometriosis organisations, resulting in an overrepresentation of individuals experiencing high impairment (De Graaff et  al., 2015). The current sample reported on average higher impairment than samples recruited via secondary and tertiary care centres (Chaman-Ara et  al., 2017), but similar levels of impairment to samples recruited via social media and endometriosis organisations (Chauvet et  al., 2017; Sullivan-Myers et  al., 2021; see Supplementary Material ). De Graaff et  al. ( 2015) point out that samples recruited via tertiary and secondary care providers are probably not representative either. This may be especially relevant for Aotearoa New Zealand where there are numerous barriers to accessing health care for endometriosis (Tewhaiti-Smith et  al., 2022). Secondly, information about endometriosis diagnosis was self-reported, rather than being verified against medical records. Moreover, whilst the number was small, some participants did not have a diagnosis through laparo - scopic surgery which is the only way to confirm an endometriosis diagnosis. Thirdly, similar to the few other studies that have looked at self-compassion and HRQoL in endometriosis, the current study was cross-sectional which limits the ability to deter - mine causality. Finally, although the EHP-30 is a well-validated scale, a limitation is that it is based on the last 4 weeks which may not accurately reflect the impact of endometriosis on quality of life. Future research should measure endometriosis symp - toms and quality of life daily to determine whether day-to-day variability in symptoms covaries with changes in quality of life. The current findings suggest that self-compassion may be a relevant area for intervention in individuals with endometriosis. Self-compassion interventions have been successful in reducing stress, anxiety, and depression in the general popula - tion (Ferrari et  al., 2019; Neff & Germer, 2013; Sommers-Spijkerman et  al., 2018) and in those with chronic health conditions, including chronic pain (Austin et  al., 2021 ; Kılıç et  al., 2021 ). In addition to reductions in depression and anxiety, a mixed-method review of compassion-based interventions (e.g. Mindful Self-Compassion, Compassion-Focused Therapy) for individuals with chronic health conditions found that many participants reported improvements in acceptance of their condition/pain, increased emotion regulation skills and reduced feelings of isolation (Austin et  al., 2021). A recent study by Torrijos-Zarcero et  al. ( 2021) found that Mindful Self-Compassion (an 8-week protocol-standardised intervention designed by Neff & Germer, 2013) improved levels of self-compassion, pain accep - tance, pain interference, catastrophising and anxiety in individuals with chronic pain. The programme outperformed the comparison condition (Cognitive Behaviour Therapy) on all measures. Given the high levels of impairment in self-image in the current sample, a self-compassionate writing intervention focussed on body image-related issues originally developed for breast cancer patients may also be relevant (Sherman et  al., 2018 ). As quality of life is shown to be impaired and access to treatment in Aotearoa New Zealand has its challenges (Tewhaiti-Smith 1492 C. M. SKINNER AND R. G. KUIJER et  al., 2022), further research is needed to determine the role that self-compassion (including compassion-based interventions) could play as a protective factor in managing the debilitating pain and other symptoms that come with endometriosis. Disclosure statement The authors report there are no competing interests to declare. Funding A PhD scholarship funded by Lottery Health Research, New Zealand, was awarded to the first author. Data availability statement The data that support the findings of this study are available on request from the corresponding author. The data is not publicly available due to ethical restrictions.

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