Effect of perceived stress on psychological distress in hepatocellular carcinoma patients undergoing TACE: the mediating role of experiential avoidance and the moderating role of trait mindfulness

Effect of perceived stress on psychological distress in hepatocellular carcinoma patients undergoing TACE: the mediating role of experiential avoidance and the moderating role of trait mindfulness | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effect of perceived stress on psychological distress in hepatocellular carcinoma patients undergoing TACE: the mediating role of experiential avoidance and the moderating role of trait mindfulness Zengxia Liu, Min Li, Yong Jia, Lufang Zheng, Li Chen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5401067/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Feb, 2025 Read the published version in BMC Cancer → Version 1 posted 4 You are reading this latest preprint version Abstract Objective The aim of this study was to explore the moderated mediation mechanism of the relationships among perceived stress, psychological distress, experiential avoidance and trait mindfulness of hepatocellular carcinoma (HCC) patients after transarterial chemoembolization (TACE) in China. Methods This study utilized a cross-sectional approach to gather data from 458 HCC patients undergoing TACE. Participants completed self-report measures assessing psychological distress, perceived stress, experiential avoidance and trait mindfulness. Mediation and moderation analyses are carried out in SPSS macro PROCESS. Results Perceived stress could affect psychological distress and experiential avoidance could mediate this relationship(mediation effect = 0.041, [95%CI=(0.027, 0.056)]). Trait mindfulness played a role as a moderator in the direct and indirect effect of perceived stress on psychological distress. Conclusion Our findings underscore the vital role of experiential avoidance and trait mindfulness to relieve psychological distress, and provide practical implications for mental health intervention programs of HCC patients undergoing TACE. psychological distress perceived stress trait mindfulness experiential avoidance hepatocellular carcinoma Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Primary liver cancer (PLC) is the third leading cause of cancer-related death(Bray et al., 2024 ). China bears a substantial burden of PLC, with accounting for 45.27% of cases and 47.12% of deaths of the global total, making it one of the most heavily affected countries (Liu et al., 2022 ). Hepatocellular carcinoma (HCC) is the most common histologic type of PLC, accounting for 75–85% of all cases. Transarterial chemoembolization (TACE) is the primary therapy choice for HCC patients who cannot undergo surgical resection. It can also be used as an adjuvant therapy for HCC patients after surgery (Chang et al., 2020 , Swierz et al., 2020 ). Due to rich blood supply and high heterogeneity, HCC are prone to formation of tumor thrombi and metastasis (Shun et al., 2012 ). Patients often need to receive multiple sessions of TACE treatment to control the progress of the disease, but they still face the risks of recurrence, metastasis and various complications after surgery (Kim et al., 2023 ). HCC patients undergoing TACE often suffer from severe psychological distress (Lan et al., 2015 ), which seriously affects their compliance to treatment and efficacy (Cao et al., 2013 , Ryu et al., 2010 , Wang et al., 2020 ). Insight of the causes and intrinsic mechanisms of psychological distress in HCC patients undergoing TACE may provide evidence for developing intervention protocols to alleviate the distress. Repeated long-term TACE treatment may lead to recurrent fear, helplessness, sadness, hopelessness and psychological stress, which is the main cause of psychological distress in HCC patients undergoing TACE (Chen et al., 2022 ). Individual psychological problems or behavioral disorders are not directly caused by the stress, but rather by the individual's erroneous cognition or irrational beliefs about the stressful event (Steenhaut et al., 2020 ). Many HCC patients undergoing TACE experience psychological distress, which is related to inappropriate emotion regulation strategies. Relational frame theory suggests that the root cause of psychological distress is mental rigidity, in which experiential avoidance acts as an important process in the model of mental rigidity, playing an important role in source of psychological distress. Avoidance is a common coping style when humans face negative experiences (Steenhaut et al., 2019 ). As an instinctive response, Individual tends to avoid annoying or unpleasant events, as well as painful thoughts, emotions and other experiences (Cookson et al., 2020 ). However, excessive use of experiential avoidance is not ineffective, but rather painful (Davidson and Kaszniak, 2015 , Gillanders et al., 2014 ). Therefore, experiential avoidance may play a mediating role between psychological stress and psychological distress. Stress can directly cause individual psychological distress (Pux et al., 2022 ). In this process, internal resources such as personality traits play a key role, while external resources such as social support exerts their effect through internal resources (Gross and John, 2003 , Marijanović et al., 2017 ). Therefore, the onset of psychological distress in HCC patients undergoing TACE is not only related to experiential avoidance, but also related to the psychological traits of patients(Shapiro et al., 2011 ). Trait mindfulness, as a positive psychological trait, can have a significant positive impact on an individual's physical health, cognitive, emotional, and behavioral problems (Brown and Ryan, 2003 , de Vibe et al., 2015 , Sala et al., 2020 ). This suggests the possibility of trait mindfulness as a protective factor for psychological distress, and trait mindfulness may be a moderating factor for psychological distress in HCC patients undergoing TACE. Taken together, perceived stress, experiential avoidance and trait mindfulness all play important roles in the emergence of psychological distress. But the possible influence of these mechanisms on psychological distress is not clear among HCC patients undergoing TACE. Hence, the present study aims to assess the prevalence of psychological distress, explore whether experiential avoidance mediates the association between perceived stress and psychological distress, and evaluate a moderated mediation model. In the moderated mediation model, we hypothesized that experiential avoidance work as a mediator between perceived stress and psychological distress among the HCC patients undergoing TACE. In addition, trait mindfulness might play a role as a moderator in the direct and/ or indirect effect (including path a: perceived stress - experiential avoidance and path b: experiential avoidance - perceived stress) of perceived stress on psychological distress, respectively, as shown in Fig. 1 . Methods 1.1 Design and participants The study was an observational cross-sectional study. It was prepared according to the STROBE Checklist. This study was conducted from October 2021 to September 2022 at a tertiary hospital in Jilin Province, China. To calculate sample size G*Power 3.1.9.4 was used. Based on a re-view of the literature (Jia et al., 2019 ), the power and alpha values were set as 0.90 and 0.05, respectively. Allowing a 20% invalid questionnaire rate, a final sample size of 438 participants was needed. The inclusion criteria were as follows: (1) Patients diagnosed with primary liver cancer according to the diagnostic criteria for liver cancer established by the European Association for the Study of the Liver (EASL) (Bruix et al., 2001 ); (2) Adult patients (≥ 18 years old) who possessed Chinese language proficiency, including reading, writing, and comprehension skills, and were capable of providing written informed consent; (3) Patients classified as Child-Pugh class A or B; (4) HCC patients undergoing TACE. Exclusion criteria included patients unable to comprehend the study's purpose, those unwilling to participate, or individuals currently diagnosed with a major psychiatric disorder. 1.2 Ethical considerations Participants were led by a researcher with expertise in psychology to ensure precise understanding of the material. Before the survey commenced, participants were given a detailed explanation of the study's objectives and importance, along with guidelines for filling out the questionnaire. They were guaranteed that their personal data would be kept private and utilized solely for research and publication purposes. Informed consent was secured from each participant. Upon survey completion, the questionnaires were gathered on-site and subsequently entered into a database following a comprehensive verification process. This study was approved by the Ethics Committee of the School of Nursing of Jilin University (ID#2019112001) and was registered in the Chinese Clinical Trial Registry (ChiCTR1900027976). 1.3 Measurement 1.3.1 Demographic characteristics The demographic and clinical characteristics, including basic sociodemographic sociological information (age, gender, marital status, education level, residence, religious affiliation, employment state and financial status) and clinical data (History of hepatitis, liver cirrhosis, Number of TACE, Family history of HCC and Child-Pugh) were collected. 1.3.2 Trait mindfulness Mindful Attention Awareness Scale (MAAS) was designed by Brown and used to evaluate the trait mindfulness (Brown and Ryan, 2003 ). This instrument measures the frequency of mindfulness states, emphasizing present-moment awareness.It consists 15 items using a 6-point Likert scale from 1( almost always) to 6 (almost never). The total score ranges from 15 to 90 points. Higher score indicates higher dispositional mindfulness and stronger ability of daily concentration and awareness for individuals. In this study, the Cronbach'α coefficient of the scale was 0.812. 1.3.3 Perceived stress Perceived stress levels were evaluated using Cohen's Perceived Stress Scale (PSS), which comprises 14 items measuring subjective stress perception including feelings related to losing control or tension (Cohen et al., 1983 ). Each item is scored on a five-point scale (0–4 points). The total score is calculated as the sum of individual item scores, with higher scores indicating greater perceived stress. The PSS demonstrated good internal consistency in this study, with a Cronbach's α coefficient of 0.76. 1.3.4 Experiential avoidance Experiential avoidance and psychological inflexibility were measured using the Acceptance and Action Questionnaire-Second Edition (AAQ-II), which consists of seven items scored on a scale from 1 to 7(Fledderus et al., 2012 ). Higher scores indicate higher levels of experiential avoidance and lower psychological flexibility, with good internal consistency demonstrated in this study (Cronbach's α = 0.85). 1.3.5 Psychological distress Psychological distress was assessed using the Hospital Anxiety and Depression Scale (HADS), consisting of 14 items scored on a scale from 0 to 3 points, with higher scores indicating greater levels of anxiety and depression(Akechi et al., 2006 ). The HADS was developed by Zigmond et al.(Edmondson et al., 2013 , Zigmond and Snaith, 1983 ). The HADS has been extensively validated in clinical practice for cancer patients, demonstrating good internal consistency in this study (Cronbach's α = 0.791). 1.4 Data Analysis SPSS, Version 25.0 (IBM, Armonk, NY, USA), was employed to conduct the data analysis. The threshold for statistical significance was set at p < .05. Descriptive statistics, independent t-tests, and one-way analysis of variance (ANOVA) were conducted to investigate variations in psychological distress across categorical socio-demographic and disease-related variables. Pearson correlation analyses were used to assess the relationships between study variables, including perceived stress, experiential avoidance, trait mindfulness, and psychological distress. The PROCESS macro for SPSS was applied to explore the mediating and moderated mediating effects, using Model 4 and Model 59, respectively. A bias-corrected 95% confidence interval (CI) was computed with 5000 bootstrap resamples, and a significant mediation or moderated mediation effect was confirmed if the interval did not encompass zero. Additionally, standardized variables were integrated into both the mediation and moderated mediation models.(Preacher and Hayes, 2008 , Zhang et al., 2021 ). Results A total of 500 questionnaires were distributed, out of which 471 questionnaires were returned (29 patients were unable to complete the questionnaire). Subsequently, 13 invalid questionnaires were excluded due to participants' unwillingness to provide essential information. Ultimately, data from 458 participants were analyzed, resulting in a response rate of 91.6%. 2.1 Sociodemographic characteristics Table 1 showed participants' sociodemographic and clinical characteristics and their different distribution of psychological distress. The mean age of the participants was 55.69 ± 8.30 years. Of the participants, 31.7% (n = 145) were women, 85.8% (n = 393) were married, 26.4% (n = 121) were College graduates, 65.1% (n = 298) lived in city, 95.9% (n = 439) has no religion,73.6% (n = 337) were unemployed, 57.8% (n = 265) had a middle-income status, 29.3% (n = 134) had no history of hepatitis, 38.0% (n = 174) had no liver cirrhosis, 31.9% (n = 146) had experienced TACE more than six times, 74.7% (n = 342) had no family history of HCC, and 51.5% of the Child-Pugh class was B (n = 236).As showed in Table 1 , psychological distress was distributed differently according to education level, financial status, liver cirrhosis, and Child-Pugh were compared and the differences were statistically significant ( p < 0.05). Table 1 Sociodemographic characteristics and the distribution of psychological distress( =458) Variables N (%) HADS( M ± SD) F/t p Age 1.460 a 0.233 18 ~ 44 years 63(13.8%) 14.4 ± 4.838 45 ~ 59 years 212(46.2%) 14.41 ± 4.482 ≥ 60 years 183(40.0%) 13.67 ± 4.427 Gender 0.700 b 0.485 Female 145(31.7%) 13.9 ± 4.706 Male 313(68.3%) 14.21 ± 4.428 Marital status -0.895 a 0.373 Married 393(85.8%) 14.03 ± 4.407 Unmarried/divorced/widowed 65(14.2%) 14.63 ± 5.125 Education level 13.850 a < 0.001 College or higher 121(26.4%) 12.31 ± 4.745 Senior high school 137(29.9%) 13.8 ± 3.881 Junior high school 125(27.3%) 15.14 ± 4.608 Primary school or below 75(16.4%) 15.91 ± 3.946 Residence 0.546 b 0.585 City 298(65.1%) 14.2 ± 4.611 Country 160(34.9%) 13.96 ± 4.341 Religious affiliation 0.475 b 0.635 None 439(95.9%) 14.13 ± 4.575 Yes 19(4.1%) 13.63 ± 2.813 Employment state -0.311 b 0.756 Unemployed 337(73.6%) 14.07 ± 4.424 Employed 121(26.4%) 14.22 ± 4.776 Economic status 10.908 a < 0.001 Low-income 130(28.4%) 15.4 ± 4.244 Middle-income 265(57.8%) 13.91 ± 4.316 High-income 63(13.8%) 12.33 ± 5.159 History of hepatitis -1.852 b 0.065 No 134(29.3%) 13.51 ± 4.719 Yes 324(70.7%) 14.36 ± 4.411 Liver cirrhosis -6.037 b 6 146(31.9%) 13.68 ± 4.733 Family history of HCC -0.709 b 0.478 No 342(74.7%) 14.03 ± 4.362 Yes 116(25.3%) 14.37 ± 4.951 Child-Pugh -2.377 b 0.018 Class A 222(48.5%) 13.6 ± 4.408 Class B 236(51.5%) 14.6 ± 4.573 Note: HADS: Hospital Anxiety and Depression Scale; a: one-way ANOVA;b:student’s t test 2.2 Correlation analysis Table 2 provided the means and correlations among the main variables. The results indicated that psychological distress was negatively correlated with trait mindfulness ( r = -0.169, p < 0.001), whereas positively correlated with perceived stress ( r = 0.504, p < 0.001), and experiential avoidance ( r = 0.561, p < 0.001). In addition, trait mindfulness had a significantly negative relation with perceived stress( r = -0.170, p < 0.001) and experiential avoidance ( r = -0.159, p < 0.001). Perceived stress was positively correlated with experiential avoidance(r = 0.313, p < 0.001). Table 2 Descriptive statistics and correlations among variables(n = 458) Variables M ± SD 1 2 3 4 1 psychological distress 14.11 ± 4.515 1 2 trait mindfulness 60.98 ± 8.292 -0.169** 1 3 perceived stress 31.50 ± 11.317 0.504** -0.170** 1 4 experiential avoidance 25.75 ± 9.162 0.561** -0.159** 0.313** 1 Note: ** p < 0.01 2.3 Mediation analysis According to the test method of the moderated mediation model, firstly, the simple mediation effect test is carried out by using Model 4 in the SPSS macro program Process(Zhang and Wang, 2022 ). The results were shown in Table 3 . After controlling for education level, financial status, liver cirrhosis, and Child-Pugh, the mediating effect of experiential avoidance between perceived stress and psychological distress showed that the regression coefficient of perceived stress on psychological distress, or the total effect was 0.171 [95% CI = (0.141, 0.201), p < 0.001], and the regression coefficient of perceived pressure on experiential avoidance was 0.233 [95% CI = (0.163, 0. 304), p < 0.001], the regression coefficient of experiential avoidance on psychological distress was 0.176 [95% CI = (0.140, 0.212), p < 0.001], the mediation effect was 0.041[95% CI = (0.027, 0.056)]. Given that the 95% confidence interval did not include 0, the mediation effect was established, with a ratio (mediation effect to total effect) of 23.98%. After controlling for the mediator variable of experiential avoidance, the regression coefficient of perceived pressure on psychological distress, or the direct effect was 0.130 [95% CI = (0.101, 0.158), p < 0.001] with a ratio (direct effect to the total effect) of 76.02%, suggesting that experiential avoidance plays a partial mediating role in the relationship between perceived pressure and psychological distress. Table 3 Mediation effect of experiential avoidance on the relationship between perceived stress and psychological distress R2 F B SE LLCI ULCI Outcome: experiential avoidance 0.140 14.650 perceived stress(Path a ) 0.233*** 0.036 0.163 0.304 Outcome: psychological distress 0.474 67.692 perceived stress(Path c’ ) 0.130*** 0.014 0.101 0.158 experiential avoidance(Path b ) 0.176*** 0.018 0.140 0.211 Note: Covariates (education level, self-rated financial status, liver cirrhosis, Child-Pugh) were controlled. B = unstandardized regression coefficient; SE = standard error, LLCI = lower level of 95% confidence interval, ULCI = upper level of 95% confidence interval. ***p < 0.001 2.4 Moderated mediation analysis Model 59 in the Process was used to test the hypothesis, with education level, financial status, liver cirrhosis, and Child-Pugh that were significant in the difference analysis as the control variables, perceived stress as an independent variable, experiential avoidance as a mediator variable, trait mindfulness as a moderating variable, and psychological distress as a dependent variable. 2,000 bootstrap resamples with a 95% confidence interval were used for analysis. After controlling for demographic variables and disease-related variables, Eq. 1 showed perceived stress had a significant positive predictive effect on experiential avoidance [ Β = 0.239, 95% CI = (0.171, 0.307)], and the interaction term between perceived stress and trait mindfulness had a significant negative predictive effect on experiential avoidance [ Β = -0.029, 95% CI = (-0.038, -0.021)], indicating that trait mindfulness can moderate the predictive role of perceived stress on experiential avoidance. In Eq. 2, after controlling for demographic variables and disease-related variables, perceived stress had a significant positive predictive effect on psychological distress [ Β = 0.135, 95% CI = (0.106, 0.164)], and the interaction term between perceived stress and trait mindfulness had a significant negative predictive effect on psychological distress [ Β = -0.011, 95% CI = (-0.014, -0.007)], indicating that trait mindfulness can mediate the predictive effect of perceived stress on psychological distress. Experiential avoidance has a significant positive predictive effect on psychological distress [ Β = 0.141, 95% CI = (0.105, 0.177)]. Interaction terms of empirical avoidance and characteristic mindfulness had significant negative predictive effects [ Β = -0.005, 95% CI = (-0.009, -0.001)], indicating that the trait mindfulness can regulate the predictive effect of experiential avoidance on psychological distress, which was detailed in Table 4 . The moderated mediator effect model of trait mindfulness on psychological distress was shown in Fig. 2 . Table 4 Moderating effect of trait mindfulness on the mediation model. B SE t LLCI ULCI Outcome: experiential avoidance perceived stress 0.239 0.035 6.894 0.171 0.307 trait mindfulness -0.113 0.047 -2.404 -0.204 -0.021 perceived stress×trait mindfulness -0.029 0.004 -6.670 -0.038 -0.021 Outcome: psychological distress perceived stress 0.135 0.015 9.199*** 0.106 0.164 experiential avoidance 0.141 0.018 7.717*** 0.105 0.177 trait mindfulness -0.013 0.018 -0.685 -0.048 0.023 perceived stress×trait mindfulness -0.011 0.002 -5.954*** -0.014 -0.007 experiential avoidance ×trait mindfulness -0.005 0.002 -2.296* -0.010 -0.001 Note: Covariates (education level, self-rated financial status, liver cirrhosis, Child-Pugh) were controlled. B: unstandardized regression coefficient; SE = standard error, LLCI = lower level of 95% confidence interval, ULCI = upper level of 95% confidence interval. ***p < 0.001 Further simple slope analysis showed that, the effect of perceived stress on psychological distress is stronger for patients with low levels of trait mindfulness [ Β = 0.224, 95% CI = (0.179, 0.268)] than for those with high levels of trait mindfulness [ Β = 0.046, 95% CI = (0 .009, 0.083)], as shown in Fig. 3 . The effect of experiential avoidance on psychological distress is stronger for patients with low levels of trait mindfulness [ Β = 0.182, 95% CI = (0.132, 0.232)] than for those with high levels of trait mindfulness [ Β = 0.100, 95% CI = (0.050, 0.150)], as shown in Fig. 4 . The direct effect size of perceived stress on experiential avoidance was the highest at low level of trait mindfulness [ Β = 0.481, 95% CI = (0.379, 0.584)], and no longer significant at high level of trait mindfulness [ Β = − 0.003, 95% CI = (-0.098, 0.092)], as shown in Fig. 5 . Discussion The results of this study showed that HCC patients undergoing TACE had more severe psychological distress, which was consistent with the results from previous studies (Compen et al., 2018 ). The results of univariate analysis indicated that general demographic data, such as education level and economic burden to the family caused by the disease, were the contributing factors to the psychological distress of HCC patients undergoing TACE. In terms of education level, patients with a higher education level have relatively more mature and stable thinking, can face various negative events more calmly, can more comprehensively understand new technologies and methods of liver cancer treatment, and treat the disease more positively and rationally. The economic burden to the family caused by the disease is also one of the factors contributing to psychological distress. Relatively high cost of TACE and need for multiple repeated treatments pose great financial burden on the patients and their families. For patients in poor families, it is also one of the important factors that cause psychological distress (Shun et al., 2012 ). Disease-related data such as liver cirrhosis and Child classification are the influencing factors of psychological distress in HCC patients undergoing TACE. HCC patients also have a relatively higher level of psychological distress. Generally, concomitant liver cirrhosis will cause more serious physical symptoms in patients (Cao et al., 2013 ), aggravating their discomfort and increasing the difficulty of treatment, which is not conducive to the patient's confidence in overcoming the disease. Therefore, their levels of psychological distress are higher. Child classification is one of the measures of liver cell damage. Severe liver function damage indicates poor compensation of the liver and serious condition of the patient. Therefore, Child classification is an important factor affecting the effect of TACE. Higher Child classification indicates worse prognosis, which seriously affects the patient's confidence in the treatment of the disease and causes more serious psychological distress. The results of this study showed a significant positive correlation between perceived stress and psychological distress in HCC patients undergoing TACE, and experiential avoidance played a partial mediating role between perceived stress and psychological distress. Firstly, perceived stress can directly predict levels of psychological distress, which is consistent with the results from previous studies (Secinti et al., 2019 , Seo, 2023 ). HCC and TACE exert a significant impact, along with the physical pain caused by the disease, the risk of tumor recurrence following TACE, and the considerable financial burden of undergoing TACE and other treatments. These factors can subject patients to substantial stress, which may, in turn, precipitate psychological distress. Moreover, perceived stress can act as an indirect predictor of the extent of psychological distress through the mechanism of experiential avoidance. Following TACE, when patients experience adverse events, such as illness, psychological pressure may ensue. Individuals might attempt to evade or avoid these negative experiences, thereby suppressing such thoughts. However, this suppression can itself engender negative thoughts, potentially leading to rumination.(Wenzlaff and Luxton, 2003). When rumination manifests as an avoidance strategy, the individual becomes engrossed in negative thoughts and abandons efforts to address the issue. Negative experiences perpetuate this cycle of rumination, creating a self-reinforcing loop from which it is difficult to escape.(Larsson et al., 2016 ). The study's findings indicated that trait mindfulness acts as a mediator on the direct paths through which perceived stress influences psychological distress. Individuals exhibiting a high level of trait mindfulness experienced a diminished impact of perceived stress on their psychological distress, a conclusion that aligns with previous research findings (Alsubaie et al., 2017 , Lindsay and Creswell, 2017 ). The correlation between dispositional mindfulness and mental health predominantly manifests through stress relief, enhancement of psychological well-being, and augmentation of a sense of well-being. Dispositional mindfulness serves as a buffer against psychological stress. A high degree of dispositional mindfulness enables individuals to maintain awareness of the present moment and to refocus on reality when distracted by intrusive thoughts (Lindsay and Creswell, 2017 ). By diminishing an individual's preoccupation with negative stimuli and adopting a more accepting stance towards adverse events, the psychological distress induced by such occurrences may be alleviated (Hsu et al., 2015 ). Trait mindfulness served as a mediating factor in the relationship between perceived stress and experiential avoidance, establishing a mediating pathway. Individuals with elevated levels of trait mindfulness experienced diminished effects of perceived stress on their tendency to avoid psychological distress. When confronted with life's negative events and pressures, those with high trait mindfulness adopted more non-judgmental attitudes(Keng et al., 2011 ), decreased their avoidance behaviors and rumination, and consequently felt a greater sense of inner peace(Vago and Silbersweig, 2012 ). This further verified the mindfulness mechanism proposed by Emily et al (Lindsay and Creswell, 2017 ). Patients with high levels of trait mindfulness can face and accept the disease (Teper and Inzlicht, 2013 ),with a positive attitude through self-regulation, correct their attitude, and use less negative emotion regulation strategies such as experiential avoidance, suppression and rumination (Joormann and Gotlib, 2010 ). Trait mindfulness served as a mediator in the pathway linking experiential avoidance to psychological distress. Individuals possessing a high level of trait mindfulness experience a diminished impact of experiential avoidance on their psychological distress. When confronted with negative events in an avoidant manner, these individuals may suppress their thoughts, a process that can lead to intensified emotional experiences and, consequently, psychological distress.(Alsubaie et al., 2017 ). Patients with high level of trait mindfulness will face them in an acceptant and less avoidant attitude, therefore having relatively fewer inner conflicts and confrontations, making them living with HCC in a more peaceful state of mind, thereby reducing psychological distress (Boyle et al., 2017 ). 3.1 Limitations This research is subject to certain limitations. Firstly, the HCC patients undergoing TACE included in this study were exclusively sourced from a single hospital, which may limit the generalizability of the findings. To enhance the validity of the results, future research could adopt a multi-center approach with a larger sample size. Secondly, this study is a cross-sectional study, which limits its ability to capture the dynamic fluctuations in perceived stress, psychological distress, experiential avoidance, and trait mindfulness among HCC patients undergoing TACE. Furthermore, the cross-sectional design does not allow for causal inferences. Future research should consider utilizing a longitudinal study design to confirm causal relations among these variables. Thirdly, it is important to acknowledge that the data in this study were collected through self-reporting, which introduces the potential for reporting bias and recall bias. 3.2 Clinical implications This study illuminates the pivotal role of perceived stress, experiential avoidance, and trait mindfulness in alleviating psychological distress among HCC patients undergoing TACE. Consequently, trait mindfulness, perceived stress, and experiential avoidance can serve as focal points for mindfulness-based interventions aimed at easing psychological distress. Within such interventions, the perceived stress of HCC patients undergoing TACE can be diminished by incorporating elements of mindfulness-based stress reduction therapy. By integrating components of acceptance and commitment therapy, empirical avoidance can be reduced and trait mindfulness levels increased in HCC patients undergoing TACE, potentially leading to a decrease in their psychological distress. This study offers a theoretical foundation for the development, execution, and elucidation of the mechanisms behind mindfulness-based intervention protocols. Conclusions In conclusion, this study emphasized the importance of experiential avoidance in alleviating psychological stress among HCC patients undergoing TACE, highlighting the pivotal role of dispositional mindfulness. The integration of mindfulness-based interventions and the reduction of experiential avoidance could effectively mitigate psychological stress in HCC patients undergoing TACE. Declarations Funding The study received financial support from University Natural Science Research Project of Anhui Provincial [grant number 2023AH050583]. CRediT authorship contribution statement Zengxia Liu: Conceptualization, Methodology, Formal analysis, Data curation, Writing -original draft, Writing-review & editing. Min Li: Methodology, Data curation. Yong Jia: Data curation, Writing-review & editing. Lufang Zheng: Data curation, Writing-review & editing. Li Chen: Project administration, Supervision. Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Acknowledgments The authors express their gratitude to all participants and healthcare staff involved in the study. References Akechi, T., et al., 2006. Screening for depression in terminally ill cancer patients in Japan. J Pain Symptom Manage. 31 (1), 5-12. Alsubaie, M., et al., 2017. 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Gillanders, D.T., et al., 2014. The development and initial validation of the cognitive fusion questionnaire. Behav Ther. 45 (1), 83-101. Gross, J.J., John, O.P., 2003. Individual differences in two emotion regulation processes: implications for affect, relationships, and well-being. J Pers Soc Psychol. 85 (2), 348-362. Hsu, K.J., et al., 2015. Transdiagnostic mechanisms in depression and anxiety: The role of rumination and attentional control. J Affect Disord. 188, 22-27. Jia, Y., et al., 2019. A nomogram for predicting depression in patients with hepatocellular carcinoma: an observational cross-sectional study. Int J Psychiatry Clin Pract. 23 (4), 273-280. Joormann, J., Gotlib, I.H., 2010. Emotion regulation in depression: relation to cognitive inhibition. Cogn Emot. 24 (2), 281-298. Keng, S.L., Smoski, M.J., Robins, C.J., 2011. Effects of mindfulness on psychological health: a review of empirical studies. Clin Psychol Rev. 31 (6), 1041-1056. Kim, M.S., Kang, M., Park, J., Ryu, J.M., 2023. Nurses' comfort care of transarterial chemoembolization patients based on their perceptions around postembolization syndrome and symptom interference. Nurs Open. 10 (5), 2877-2885. Lan, S.C., Lin, Y.E., Chen, S.C., Lin, Y.F., Wang, Y.J., 2015. Effects of acupressure on fatigue and depression in hepatocellular carcinoma patients treated with transcatheter arterial chemoembolization: a quasi-experimental study. Evid Based Complement Alternat Med. 2015, 496485. Larsson, A., Hooper, N., Osborne, L.A., Bennett, P., McHugh, L., 2016. Using Brief Cognitive Restructuring and Cognitive Defusion Techniques to Cope With Negative Thoughts. Behav Modif. 40 (3), 452-482. Lindsay, E.K., Creswell, J.D., 2017. Mechanisms of mindfulness training: Monitor and Acceptance Theory (MAT). Clin Psychol Rev. 51, 48-59. Liu, Z., et al., 2022. A randomized clinical trial of guided self-help intervention based on mindfulness for patients with hepatocellular carcinoma: effects and mechanisms. Jpn J Clin Oncol. 52 (3), 227-236. Marijanović, I., Pavleković, G., Buhovac, T., Martinac, M., 2017. The relationship between health locus of control, depression, and sociodemographic factors and amount of time breast cancer patients wait before seeking diagnosis and treatment. Psychiatr Danub. 29 (3), 330-344. Preacher, K.J., Hayes, A.F., 2008. Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behav Res Methods. 40 (3), 879-891. Pux, S., et al., 2022. Cognitive fusion and personality traits in the context of mindfulness: A cross-sectional study. PLoS One. 17 (9), e0273331. Ryu, E., et al., 2010. Symptom clusters and quality of life in Korean patients with hepatocellular carcinoma. Cancer Nurs. 33 (1), 3-10. Sala, M., Rochefort, C., Lui, P.P., Baldwin, A.S., 2020. Trait mindfulness and health behaviours: a meta-analysis. Health Psychol Rev. 14 (3), 345-393. Secinti, E., Tometich, D.B., Johns, S.A., Mosher, C.E., 2019. The relationship between acceptance of cancer and distress: A meta-analytic review. Clin Psychol Rev. 71, 27-38. Seo, K., 2023. The Mediating Effect of Experiential Avoidance on the Relationship between Diabetes Distress and Self-Stigma in People with Diabetes Mellitus Type 2 in Republic of Korea. Healthcare (Basel). 11 (20). Shapiro, S.L., Brown, K.W., Thoresen, C., Plante, T.G., 2011. The moderation of Mindfulness-based stress reduction effects by trait mindfulness: results from a randomized controlled trial. J Clin Psychol. 67 (3), 267-277. Shun, S.C., et al., 2012. Quality of life and its associated factors in patients with hepatocellular carcinoma receiving one course of transarterial chemoembolization treatment: a longitudinal study. Oncologist. 17 (5), 732-739. Steenhaut, P., Rossi, G., Demeyer, I., De Raedt, R., 2020. Flexibility as a Mediator between Personality and Well-Being in Older and Younger Adults: Findings from Questionnaire Data and a Behavioral Task. Exp Aging Res. 46 (5), 446-468. Steenhaut, P., Rossi, G., Demeyer, I., De Raedt, R., 2019. How is personality related to well-being in older and younger adults? The role of psychological flexibility. Int Psychogeriatr. 31 (9), 1355-1365. Swierz, M.J., et al., 2020. Transarterial (chemo)embolisation versus no intervention or placebo for liver metastases. Cochrane Database Syst Rev. 3 (3), CD009498. Teper, R., Inzlicht, M., 2013. Meditation, mindfulness and executive control: the importance of emotional acceptance and brain-based performance monitoring. Soc Cogn Affect Neurosci. 8 (1), 85-92. Vago, D.R., Silbersweig, D.A., 2012. Self-awareness, self-regulation, and self-transcendence (S-ART): a framework for understanding the neurobiological mechanisms of mindfulness. Front Hum Neurosci. 6, 296. Wang, Y.H., et al., 2020. Depression and anxiety in relation to cancer incidence and mortality: a systematic review and meta-analysis of cohort studies. Mol Psychiatry. 25 (7), 1487-1499. Wenzlaff, R.M.D.o.P., U Texas at San Antonio, San Antonio, TX, US, [email protected] , Luxton, D.D.D.o.P., U Texas at San Antonio, San Antonio, TX, US, 2003. The Role of Thought Suppression in Depressive Rumination %J Cognitive Therapy and Research. (No.3), 293-308. Zhang, D., et al., 2021. Role of resilience and social support in the relationship between loneliness and suicidal ideation among Chinese nursing home residents. Aging Ment Health. 25 (7), 1262-1272. Zhang, J., Wang, E., 2022. Indulging in Smartphones in Times of Stress: A Moderated Mediation Model of Experiential Avoidance and Trait Mindfulness. Behav Sci (Basel). 12 (12). Zigmond, A.S., Snaith, R.P., 1983. The hospital anxiety and depression scale. Acta Psychiatr Scand. 67 (6), 361-370. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 13 Feb, 2025 Read the published version in BMC Cancer → Version 1 posted Editorial decision: Revision requested 07 Nov, 2024 Editor assigned by journal 06 Nov, 2024 Submission checks completed at journal 06 Nov, 2024 First submitted to journal 06 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5401067","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":375446202,"identity":"bc75c9d3-cd1b-48bb-a085-874c5a08a3cd","order_by":0,"name":"Zengxia Liu","email":"","orcid":"","institution":"Anhui medical University","correspondingAuthor":false,"prefix":"","firstName":"Zengxia","middleName":"","lastName":"Liu","suffix":""},{"id":375446203,"identity":"5f1515f6-8cdf-453c-8030-80670bfb26ff","order_by":1,"name":"Min Li","email":"","orcid":"","institution":"First Hospital of Jilin University","correspondingAuthor":false,"prefix":"","firstName":"Min","middleName":"","lastName":"Li","suffix":""},{"id":375446204,"identity":"94e59fad-1ce0-413e-b16d-bed5944b61ed","order_by":2,"name":"Yong Jia","email":"","orcid":"","institution":"Jilin University","correspondingAuthor":false,"prefix":"","firstName":"Yong","middleName":"","lastName":"Jia","suffix":""},{"id":375446205,"identity":"6f18a732-ad33-4dc6-a5af-b0fc20bd1e72","order_by":3,"name":"Lufang Zheng","email":"","orcid":"","institution":"Jilin University","correspondingAuthor":false,"prefix":"","firstName":"Lufang","middleName":"","lastName":"Zheng","suffix":""},{"id":375446206,"identity":"1a3e6608-0723-48f7-a51d-d18d236cdb43","order_by":4,"name":"Li Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwklEQVRIiWNgGAWjYDACCRiDvbHxwQfStPAcbjacQZoWifQ2aQ5idPDPbj72gKHGLp9f8mGDNAODnZxuAyFL7hxLN2A4lmw5c3Zig3EBQ7Kx2QECWgwkcswkGBuYDQxuJzYkz2A4kLiNsJb8b0At9Qb2Nw82HOYhTksOG1DLYQMDCcbGZqK0SNxIM5NgOHbcQOJMYjPjDAMi/MI/I/mZBENNtQF/+/HnPz5U2MkR1AICzH8Q7iRC+SgYBaNgFIwCwgAATI089V3MW4cAAAAASUVORK5CYII=","orcid":"","institution":"Jilin University","correspondingAuthor":true,"prefix":"","firstName":"Li","middleName":"","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2024-11-06 08:53:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5401067/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5401067/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12885-025-13679-y","type":"published","date":"2025-02-13T15:58:12+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":70922689,"identity":"0a81e926-7617-47ca-97c4-a78fed05ec4d","added_by":"auto","created_at":"2024-12-09 08:52:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":39626,"visible":true,"origin":"","legend":"\u003cp\u003eThe assumptive mediated moderation model.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5401067/v1/4e22b95a8be0481bea7bce8c.png"},{"id":70922693,"identity":"4755d231-9690-4417-bcc0-27252c755277","added_by":"auto","created_at":"2024-12-09 08:52:04","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":140350,"visible":true,"origin":"","legend":"\u003cp\u003eThe final moderated mediation model.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-5401067/v1/021dcd2c5c7330e98e017924.png"},{"id":70924288,"identity":"955965b0-f514-4635-994c-af7fe72a9225","added_by":"auto","created_at":"2024-12-09 09:00:04","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":123358,"visible":true,"origin":"","legend":"\u003cp\u003eTrait mindfulness as a moderator in the association between perceived stress and psychological distress\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-5401067/v1/d427bd058ec76809a19bf036.png"},{"id":70922691,"identity":"4ed09688-e885-4433-95bd-ceeac44b583c","added_by":"auto","created_at":"2024-12-09 08:52:04","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":28077,"visible":true,"origin":"","legend":"\u003cp\u003eTrait mindfulness as a moderator in the association between experiential avoidance and psychological distress\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-5401067/v1/311e4c0982085c2a3de3b152.png"},{"id":70922694,"identity":"c062d8e0-8aab-482d-a1c6-7e688267b080","added_by":"auto","created_at":"2024-12-09 08:52:04","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":28582,"visible":true,"origin":"","legend":"\u003cp\u003eTrait mindfulness as a moderator in the association between perceived stress and experiential avoidance\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-5401067/v1/87d7d21916dd9bcf189c995d.png"},{"id":76487663,"identity":"aff79e3b-07e6-42f1-b1e4-252120e2fe43","added_by":"auto","created_at":"2025-02-17 16:10:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1175969,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5401067/v1/d29fa8b1-9f04-4d58-bf08-5ebdeaedfc72.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect of perceived stress on psychological distress in hepatocellular carcinoma patients undergoing TACE: the mediating role of experiential avoidance and the moderating role of trait mindfulness","fulltext":[{"header":"Background","content":"\u003cp\u003ePrimary liver cancer (PLC) is the third leading cause of cancer-related death(Bray et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). China bears a substantial burden of PLC, with accounting for 45.27% of cases and 47.12% of deaths of the global total, making it one of the most heavily affected countries (Liu et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Hepatocellular carcinoma (HCC) is the most common histologic type of PLC, accounting for 75\u0026ndash;85% of all cases. Transarterial chemoembolization (TACE) is the primary therapy choice for HCC patients who cannot undergo surgical resection. It can also be used as an adjuvant therapy for HCC patients after surgery (Chang et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2020\u003c/span\u003e, Swierz et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Due to rich blood supply and high heterogeneity, HCC are prone to formation of tumor thrombi and metastasis (Shun et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Patients often need to receive multiple sessions of TACE treatment to control the progress of the disease, but they still face the risks of recurrence, metastasis and various complications after surgery (Kim et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). HCC patients undergoing TACE often suffer from severe psychological distress (Lan et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), which seriously affects their compliance to treatment and efficacy (Cao et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2013\u003c/span\u003e, Ryu et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2010\u003c/span\u003e, Wang et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eInsight of the causes and intrinsic mechanisms of psychological distress in HCC patients undergoing TACE may provide evidence for developing intervention protocols to alleviate the distress. Repeated long-term TACE treatment may lead to recurrent fear, helplessness, sadness, hopelessness and psychological stress, which is the main cause of psychological distress in HCC patients undergoing TACE (Chen et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Individual psychological problems or behavioral disorders are not directly caused by the stress, but rather by the individual's erroneous cognition or irrational beliefs about the stressful event (Steenhaut et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Many HCC patients undergoing TACE experience psychological distress, which is related to inappropriate emotion regulation strategies. Relational frame theory suggests that the root cause of psychological distress is mental rigidity, in which experiential avoidance acts as an important process in the model of mental rigidity, playing an important role in source of psychological distress. Avoidance is a common coping style when humans face negative experiences (Steenhaut et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). As an instinctive response, Individual tends to avoid annoying or unpleasant events, as well as painful thoughts, emotions and other experiences (Cookson et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). However, excessive use of experiential avoidance is not ineffective, but rather painful (Davidson and Kaszniak, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2015\u003c/span\u003e, Gillanders et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Therefore, experiential avoidance may play a mediating role between psychological stress and psychological distress.\u003c/p\u003e \u003cp\u003eStress can directly cause individual psychological distress (Pux et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In this process, internal resources such as personality traits play a key role, while external resources such as social support exerts their effect through internal resources (Gross and John, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2003\u003c/span\u003e, Marijanović et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Therefore, the onset of psychological distress in HCC patients undergoing TACE is not only related to experiential avoidance, but also related to the psychological traits of patients(Shapiro et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Trait mindfulness, as a positive psychological trait, can have a significant positive impact on an individual's physical health, cognitive, emotional, and behavioral problems (Brown and Ryan, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2003\u003c/span\u003e, de Vibe et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2015\u003c/span\u003e, Sala et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). This suggests the possibility of trait mindfulness as a protective factor for psychological distress, and trait mindfulness may be a moderating factor for psychological distress in HCC patients undergoing TACE.\u003c/p\u003e \u003cp\u003eTaken together, perceived stress, experiential avoidance and trait mindfulness all play important roles in the emergence of psychological distress. But the possible influence of these mechanisms on psychological distress is not clear among HCC patients undergoing TACE. Hence, the present study aims to assess the prevalence of psychological distress, explore whether experiential avoidance mediates the association between perceived stress and psychological distress, and evaluate a moderated mediation model. In the moderated mediation model, we hypothesized that experiential avoidance work as a mediator between perceived stress and psychological distress among the HCC patients undergoing TACE. In addition, trait mindfulness might play a role as a moderator in the direct and/ or indirect effect (including path a: perceived stress - experiential avoidance and path b: experiential avoidance - perceived stress) of perceived stress on psychological distress, respectively, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e1.1 Design and participants\u003c/h2\u003e \u003cp\u003eThe study was an observational cross-sectional study. It was prepared according to the STROBE Checklist. This study was conducted from October 2021 to September 2022 at a tertiary hospital in Jilin Province, China. To calculate sample size G*Power 3.1.9.4 was used. Based on a re-view of the literature (Jia et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), the power and alpha values were set as 0.90 and 0.05, respectively. Allowing a 20% invalid questionnaire rate, a final sample size of 438 participants was needed.\u003c/p\u003e \u003cp\u003eThe inclusion criteria were as follows: (1) Patients diagnosed with primary liver cancer according to the diagnostic criteria for liver cancer established by the European Association for the Study of the Liver (EASL) (Bruix et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2001\u003c/span\u003e); (2) Adult patients (\u0026ge;\u0026thinsp;18 years old) who possessed Chinese language proficiency, including reading, writing, and comprehension skills, and were capable of providing written informed consent; (3) Patients classified as Child-Pugh class A or B; (4) HCC patients undergoing TACE. Exclusion criteria included patients unable to comprehend the study's purpose, those unwilling to participate, or individuals currently diagnosed with a major psychiatric disorder.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e1.2 Ethical considerations\u003c/h3\u003e\n\u003cp\u003eParticipants were led by a researcher with expertise in psychology to ensure precise understanding of the material. Before the survey commenced, participants were given a detailed explanation of the study's objectives and importance, along with guidelines for filling out the questionnaire. They were guaranteed that their personal data would be kept private and utilized solely for research and publication purposes. Informed consent was secured from each participant. Upon survey completion, the questionnaires were gathered on-site and subsequently entered into a database following a comprehensive verification process. This study was approved by the Ethics Committee of the School of Nursing of Jilin University (ID#2019112001) and was registered in the Chinese Clinical Trial Registry (ChiCTR1900027976).\u003c/p\u003e\n\u003ch3\u003e1.3 Measurement\u003c/h3\u003e\n\u003cp\u003e1.3.1 Demographic characteristics\u003c/p\u003e \u003cp\u003eThe demographic and clinical characteristics, including basic sociodemographic sociological information (age, gender, marital status, education level, residence, religious affiliation, employment state and financial status) and clinical data (History of hepatitis, liver cirrhosis, Number of TACE, Family history of HCC and Child-Pugh) were collected.\u003c/p\u003e \u003cp\u003e1.3.2 Trait mindfulness\u003c/p\u003e \u003cp\u003eMindful Attention Awareness Scale (MAAS) was designed by Brown and used to evaluate the trait mindfulness (Brown and Ryan, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2003\u003c/span\u003e). This instrument measures the frequency of mindfulness states, emphasizing present-moment awareness.It consists 15 items using a 6-point Likert scale from 1( almost always) to 6 (almost never). The total score ranges from 15 to 90 points. Higher score indicates higher dispositional mindfulness and stronger ability of daily concentration and awareness for individuals. In this study, the Cronbach'α coefficient of the scale was 0.812.\u003c/p\u003e \u003cp\u003e1.3.3 Perceived stress\u003c/p\u003e \u003cp\u003ePerceived stress levels were evaluated using Cohen's Perceived Stress Scale (PSS), which comprises 14 items measuring subjective stress perception including feelings related to losing control or tension (Cohen et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e1983\u003c/span\u003e). Each item is scored on a five-point scale (0\u0026ndash;4 points). The total score is calculated as the sum of individual item scores, with higher scores indicating greater perceived stress. The PSS demonstrated good internal consistency in this study, with a Cronbach's α coefficient of 0.76.\u003c/p\u003e \u003cp\u003e1.3.4 Experiential avoidance\u003c/p\u003e \u003cp\u003eExperiential avoidance and psychological inflexibility were measured using the Acceptance and Action Questionnaire-Second Edition (AAQ-II), which consists of seven items scored on a scale from 1 to 7(Fledderus et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Higher scores indicate higher levels of experiential avoidance and lower psychological flexibility, with good internal consistency demonstrated in this study (Cronbach's α\u0026thinsp;=\u0026thinsp;0.85).\u003c/p\u003e \u003cp\u003e1.3.5 Psychological distress\u003c/p\u003e \u003cp\u003ePsychological distress was assessed using the Hospital Anxiety and Depression Scale (HADS), consisting of 14 items scored on a scale from 0 to 3 points, with higher scores indicating greater levels of anxiety and depression(Akechi et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). The HADS was developed by Zigmond et al.(Edmondson et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2013\u003c/span\u003e, Zigmond and Snaith, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e1983\u003c/span\u003e). The HADS has been extensively validated in clinical practice for cancer patients, demonstrating good internal consistency in this study (Cronbach's α\u0026thinsp;=\u0026thinsp;0.791).\u003c/p\u003e\n\u003ch3\u003e1.4 Data Analysis\u003c/h3\u003e\n\u003cp\u003eSPSS, Version 25.0 (IBM, Armonk, NY, USA), was employed to conduct the data analysis. The threshold for statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;.05. Descriptive statistics, independent t-tests, and one-way analysis of variance (ANOVA) were conducted to investigate variations in psychological distress across categorical socio-demographic and disease-related variables. Pearson correlation analyses were used to assess the relationships between study variables, including perceived stress, experiential avoidance, trait mindfulness, and psychological distress. The PROCESS macro for SPSS was applied to explore the mediating and moderated mediating effects, using Model 4 and Model 59, respectively. A bias-corrected 95% confidence interval (CI) was computed with 5000 bootstrap resamples, and a significant mediation or moderated mediation effect was confirmed if the interval did not encompass zero. Additionally, standardized variables were integrated into both the mediation and moderated mediation models.(Preacher and Hayes, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2008\u003c/span\u003e, Zhang et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 500 questionnaires were distributed, out of which 471 questionnaires were returned (29 patients were unable to complete the questionnaire). Subsequently, 13 invalid questionnaires were excluded due to participants' unwillingness to provide essential information. Ultimately, data from 458 participants were analyzed, resulting in a response rate of 91.6%.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Sociodemographic characteristics\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e showed participants' sociodemographic and clinical characteristics and their different distribution of psychological distress. The mean age of the participants was 55.69 ± 8.30 years. Of the participants, 31.7% (n = 145) were women, 85.8% (n = 393) were married, 26.4% (n = 121) were College graduates, 65.1% (n = 298) lived in city, 95.9% (n = 439) has no religion,73.6% (n = 337) were unemployed, 57.8% (n = 265) had a middle-income status, 29.3% (n = 134) had no history of hepatitis, 38.0% (n = 174) had no liver cirrhosis, 31.9% (n = 146) had experienced TACE more than six times, 74.7% (n = 342) had no family history of HCC, and 51.5% of the Child-Pugh class was B (n = 236).As showed in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, psychological distress was distributed differently according to education level, financial status, liver cirrhosis, and Child-Pugh were compared and the differences were statistically significant (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"±\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic characteristics and the distribution of psychological distress( =458)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eN\u003c/em\u003e(%)\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHADS(\u003cem\u003eM\u003c/em\u003e ± SD)\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eF/t\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.460\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.233\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18 ~ 44 years\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e63(13.8%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e14.4 ± 4.838\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e45 ~ 59 years\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e212(46.2%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e14.41 ± 4.482\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e≥ 60 years\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e183(40.0%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e13.67 ± 4.427\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.700\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.485\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e145(31.7%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e13.9 ± 4.706\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e313(68.3%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e14.21 ± 4.428\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.895\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.373\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e393(85.8%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e14.03 ± 4.407\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnmarried/divorced/widowed\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e65(14.2%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e14.63 ± 5.125\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation level\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.850\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollege or higher\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e121(26.4%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e12.31 ± 4.745\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSenior high school\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e137(29.9%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e13.8 ± 3.881\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJunior high school\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e125(27.3%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e15.14 ± 4.608\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary school or below\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e75(16.4%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e15.91 ± 3.946\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidence\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.546\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.585\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCity\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e298(65.1%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e14.2 ± 4.611\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e160(34.9%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e13.96 ± 4.341\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReligious affiliation\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.475\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.635\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e439(95.9%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e14.13 ± 4.575\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19(4.1%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e13.63 ± 2.813\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployment state\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.311\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.756\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e337(73.6%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e14.07 ± 4.424\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e121(26.4%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e14.22 ± 4.776\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEconomic status\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.908\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow-income\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e130(28.4%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e15.4 ± 4.244\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle-income\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e265(57.8%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e13.91 ± 4.316\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh-income\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e63(13.8%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e12.33 ± 5.159\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of hepatitis\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1.852 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.065\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e134(29.3%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e13.51 ± 4.719\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e324(70.7%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e14.36 ± 4.411\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiver cirrhosis\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-6.037 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e174(38.0%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e12.55 ± 4.411\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e284 (62.0%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e15.07 ± 4.312\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of TACE\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.756 \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.174\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39(8.5%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e13.49 ± 5.453\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2–6\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e273(59.6%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e14.44 ± 4.232\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt; 6\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e146(31.9%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e13.68 ± 4.733\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily history of HCC\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.709 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.478\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e342(74.7%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e14.03 ± 4.362\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e116(25.3%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e14.37 ± 4.951\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild-Pugh\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-2.377 \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClass A\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e222(48.5%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e13.6 ± 4.408\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClass B\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e236(51.5%)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e14.6 ± 4.573\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eNote: HADS: Hospital Anxiety and Depression Scale; a: one-way ANOVA;b:student’s t test\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e2.2 Correlation analysis\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e provided the means and correlations among the main variables. The results indicated that psychological distress was negatively correlated with trait mindfulness (\u003cem\u003er\u003c/em\u003e = -0.169, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), whereas positively correlated with perceived stress (\u003cem\u003er\u003c/em\u003e = 0.504, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), and experiential avoidance (\u003cem\u003er\u003c/em\u003e = 0.561, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001). In addition, trait mindfulness had a significantly negative relation with perceived stress(\u003cem\u003er\u003c/em\u003e = -0.170, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001) and experiential avoidance (\u003cem\u003er\u003c/em\u003e = -0.159, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001). Perceived stress was positively correlated with experiential avoidance(r = 0.313, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"±\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive statistics and correlations among variables(n = 458)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM ± SD\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 psychological distress\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c2\"\u003e \u003cp\u003e14.11 ± 4.515\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2 trait mindfulness\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c2\"\u003e \u003cp\u003e60.98 ± 8.292\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.169**\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 perceived stress\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c2\"\u003e \u003cp\u003e31.50 ± 11.317\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.504**\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.170**\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4 experiential avoidance\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c2\"\u003e \u003cp\u003e25.75 ± 9.162\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.561**\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.159**\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.313**\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote: **\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.01\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e\n\u003ch3\u003e2.3 Mediation analysis\u003c/h3\u003e\n\u003cp\u003eAccording to the test method of the moderated mediation model, firstly, the simple mediation effect test is carried out by using Model 4 in the SPSS macro program Process(Zhang and Wang, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The results were shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. After controlling for education level, financial status, liver cirrhosis, and Child-Pugh, the mediating effect of experiential avoidance between perceived stress and psychological distress showed that the regression coefficient of perceived stress on psychological distress, or the total effect was 0.171 [95% CI = (0.141, 0.201), \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001], and the regression coefficient of perceived pressure on experiential avoidance was 0.233 [95% CI = (0.163, 0. 304), \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001], the regression coefficient of experiential avoidance on psychological distress was 0.176 [95% CI = (0.140, 0.212), \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001], the mediation effect was 0.041[95% CI = (0.027, 0.056)]. Given that the 95% confidence interval did not include 0, the mediation effect was established, with a ratio (mediation effect to total effect) of 23.98%. After controlling for the mediator variable of experiential avoidance, the regression coefficient of perceived pressure on psychological distress, or the direct effect was 0.130 [95% CI = (0.101, 0.158), \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001] with a ratio (direct effect to the total effect) of 76.02%, suggesting that experiential avoidance plays a partial mediating role in the relationship between perceived pressure and psychological distress.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMediation effect of experiential avoidance on the relationship between perceived stress and psychological distress\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eR2\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLLCI\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eULCI\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome: experiential avoidance\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.140\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.650\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eperceived stress(Path \u003cem\u003ea\u003c/em\u003e)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.233***\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.036\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.163\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.304\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome: psychological distress\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.474\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e67.692\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eperceived stress(Path \u003cem\u003ec’\u003c/em\u003e)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.130***\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.014\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.101\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.158\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eexperiential avoidance(Path \u003cem\u003eb\u003c/em\u003e)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.176***\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.140\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.211\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote: Covariates (education level, self-rated financial status, liver cirrhosis, Child-Pugh) were controlled. B = unstandardized regression coefficient; SE = standard error, LLCI = lower level of 95% confidence interval, ULCI = upper level of 95% confidence interval. ***p \u0026lt; 0.001\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Moderated mediation analysis\u003c/h2\u003e \u003cp\u003eModel 59 in the Process was used to test the hypothesis, with education level, financial status, liver cirrhosis, and Child-Pugh that were significant in the difference analysis as the control variables, perceived stress as an independent variable, experiential avoidance as a mediator variable, trait mindfulness as a moderating variable, and psychological distress as a dependent variable. 2,000 bootstrap resamples with a 95% confidence interval were used for analysis. After controlling for demographic variables and disease-related variables, Eq.\u0026nbsp;1 showed perceived stress had a significant positive predictive effect on experiential avoidance [\u003cem\u003eΒ\u003c/em\u003e = 0.239, 95% CI = (0.171, 0.307)], and the interaction term between perceived stress and trait mindfulness had a significant negative predictive effect on experiential avoidance [\u003cem\u003eΒ\u003c/em\u003e = -0.029, 95% CI = (-0.038, -0.021)], indicating that trait mindfulness can moderate the predictive role of perceived stress on experiential avoidance.\u003c/p\u003e \u003cp\u003eIn Eq.\u0026nbsp;2, after controlling for demographic variables and disease-related variables, perceived stress had a significant positive predictive effect on psychological distress [\u003cem\u003eΒ\u003c/em\u003e = 0.135, 95% CI = (0.106, 0.164)], and the interaction term between perceived stress and trait mindfulness had a significant negative predictive effect on psychological distress [\u003cem\u003eΒ\u003c/em\u003e= -0.011, 95% CI = (-0.014, -0.007)], indicating that trait mindfulness can mediate the predictive effect of perceived stress on psychological distress. Experiential avoidance has a significant positive predictive effect on psychological distress [\u003cem\u003eΒ\u003c/em\u003e = 0.141, 95% CI = (0.105, 0.177)]. Interaction terms of empirical avoidance and characteristic mindfulness had significant negative predictive effects [\u003cem\u003eΒ\u003c/em\u003e= -0.005, 95% CI = (-0.009, -0.001)], indicating that the trait mindfulness can regulate the predictive effect of experiential avoidance on psychological distress, which was detailed in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. The moderated mediator effect model of trait mindfulness on psychological distress was shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eModerating effect of trait mindfulness on the mediation model.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLLCI\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eULCI\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome: experiential avoidance\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eperceived stress\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.239\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.035\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.894\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.171\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.307\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003etrait mindfulness\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.113\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.047\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-2.404\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.204\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.021\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eperceived stress×trait mindfulness\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.029\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-6.670\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.038\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.021\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome: psychological distress\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eperceived stress\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.135\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.199***\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.106\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.164\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eexperiential avoidance\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.141\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.717***\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.105\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.177\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003etrait mindfulness\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.013\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.685\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.048\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.023\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eperceived stress×trait mindfulness\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.011\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-5.954***\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.014\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.007\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eexperiential avoidance ×trait mindfulness\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.005\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-2.296*\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.010\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.001\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote: Covariates (education level, self-rated financial status, liver cirrhosis, Child-Pugh) were controlled. B: unstandardized regression coefficient; SE = standard error, LLCI = lower level of 95% confidence interval, ULCI = upper level of 95% confidence interval. ***p \u0026lt; 0.001\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFurther simple slope analysis showed that, the effect of perceived stress on psychological distress is stronger for patients with low levels of trait mindfulness [\u003cem\u003eΒ\u003c/em\u003e = 0.224, 95% CI = (0.179, 0.268)] than for those with high levels of trait mindfulness [\u003cem\u003eΒ\u003c/em\u003e = 0.046, 95% CI = (0 .009, 0.083)], as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The effect of experiential avoidance on psychological distress is stronger for patients with low levels of trait mindfulness [\u003cem\u003eΒ\u003c/em\u003e = 0.182, 95% CI = (0.132, 0.232)] than for those with high levels of trait mindfulness [\u003cem\u003eΒ\u003c/em\u003e = 0.100, 95% CI = (0.050, 0.150)], as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. The direct effect size of perceived stress on experiential avoidance was the highest at low level of trait mindfulness [\u003cem\u003eΒ\u003c/em\u003e = 0.481, 95% CI = (0.379, 0.584)], and no longer significant at high level of trait mindfulness [\u003cem\u003eΒ\u003c/em\u003e= − 0.003, 95% CI = (-0.098, 0.092)], as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e "},{"header":"Discussion","content":"\u003cp\u003eThe results of this study showed that HCC patients undergoing TACE had more severe psychological distress, which was consistent with the results from previous studies (Compen et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). The results of univariate analysis indicated that general demographic data, such as education level and economic burden to the family caused by the disease, were the contributing factors to the psychological distress of HCC patients undergoing TACE. In terms of education level, patients with a higher education level have relatively more mature and stable thinking, can face various negative events more calmly, can more comprehensively understand new technologies and methods of liver cancer treatment, and treat the disease more positively and rationally. The economic burden to the family caused by the disease is also one of the factors contributing to psychological distress. Relatively high cost of TACE and need for multiple repeated treatments pose great financial burden on the patients and their families. For patients in poor families, it is also one of the important factors that cause psychological distress (Shun et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDisease-related data such as liver cirrhosis and Child classification are the influencing factors of psychological distress in HCC patients undergoing TACE. HCC patients also have a relatively higher level of psychological distress. Generally, concomitant liver cirrhosis will cause more serious physical symptoms in patients (Cao et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2013\u003c/span\u003e), aggravating their discomfort and increasing the difficulty of treatment, which is not conducive to the patient's confidence in overcoming the disease. Therefore, their levels of psychological distress are higher. Child classification is one of the measures of liver cell damage. Severe liver function damage indicates poor compensation of the liver and serious condition of the patient. Therefore, Child classification is an important factor affecting the effect of TACE. Higher Child classification indicates worse prognosis, which seriously affects the patient's confidence in the treatment of the disease and causes more serious psychological distress.\u003c/p\u003e\u003cp\u003eThe results of this study showed a significant positive correlation between perceived stress and psychological distress in HCC patients undergoing TACE, and experiential avoidance played a partial mediating role between perceived stress and psychological distress. Firstly, perceived stress can directly predict levels of psychological distress, which is consistent with the results from previous studies (Secinti et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2019\u003c/span\u003e, Seo, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). HCC and TACE exert a significant impact, along with the physical pain caused by the disease, the risk of tumor recurrence following TACE, and the considerable financial burden of undergoing TACE and other treatments. These factors can subject patients to substantial stress, which may, in turn, precipitate psychological distress. Moreover, perceived stress can act as an indirect predictor of the extent of psychological distress through the mechanism of experiential avoidance. Following TACE, when patients experience adverse events, such as illness, psychological pressure may ensue. Individuals might attempt to evade or avoid these negative experiences, thereby suppressing such thoughts. However, this suppression can itself engender negative thoughts, potentially leading to rumination.(Wenzlaff and Luxton, 2003). When rumination manifests as an avoidance strategy, the individual becomes engrossed in negative thoughts and abandons efforts to address the issue. Negative experiences perpetuate this cycle of rumination, creating a self-reinforcing loop from which it is difficult to escape.(Larsson et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe study's findings indicated that trait mindfulness acts as a mediator on the direct paths through which perceived stress influences psychological distress. Individuals exhibiting a high level of trait mindfulness experienced a diminished impact of perceived stress on their psychological distress, a conclusion that aligns with previous research findings (Alsubaie et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2017\u003c/span\u003e, Lindsay and Creswell, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). The correlation between dispositional mindfulness and mental health predominantly manifests through stress relief, enhancement of psychological well-being, and augmentation of a sense of well-being. Dispositional mindfulness serves as a buffer against psychological stress. A high degree of dispositional mindfulness enables individuals to maintain awareness of the present moment and to refocus on reality when distracted by intrusive thoughts (Lindsay and Creswell, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). By diminishing an individual's preoccupation with negative stimuli and adopting a more accepting stance towards adverse events, the psychological distress induced by such occurrences may be alleviated (Hsu et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2015\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTrait mindfulness served as a mediating factor in the relationship between perceived stress and experiential avoidance, establishing a mediating pathway. Individuals with elevated levels of trait mindfulness experienced diminished effects of perceived stress on their tendency to avoid psychological distress. When confronted with life's negative events and pressures, those with high trait mindfulness adopted more non-judgmental attitudes(Keng et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2011\u003c/span\u003e), decreased their avoidance behaviors and rumination, and consequently felt a greater sense of inner peace(Vago and Silbersweig, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). This further verified the mindfulness mechanism proposed by Emily et al (Lindsay and Creswell, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Patients with high levels of trait mindfulness can face and accept the disease (Teper and Inzlicht, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2013\u003c/span\u003e),with a positive attitude through self-regulation, correct their attitude, and use less negative emotion regulation strategies such as experiential avoidance, suppression and rumination (Joormann and Gotlib, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2010\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTrait mindfulness served as a mediator in the pathway linking experiential avoidance to psychological distress. Individuals possessing a high level of trait mindfulness experience a diminished impact of experiential avoidance on their psychological distress. When confronted with negative events in an avoidant manner, these individuals may suppress their thoughts, a process that can lead to intensified emotional experiences and, consequently, psychological distress.(Alsubaie et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Patients with high level of trait mindfulness will face them in an acceptant and less avoidant attitude, therefore having relatively fewer inner conflicts and confrontations, making them living with HCC in a more peaceful state of mind, thereby reducing psychological distress (Boyle et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e\u003ch2\u003e3.1 Limitations\u003c/h2\u003e\u003cp\u003eThis research is subject to certain limitations. Firstly, the HCC patients undergoing TACE included in this study were exclusively sourced from a single hospital, which may limit the generalizability of the findings. To enhance the validity of the results, future research could adopt a multi-center approach with a larger sample size. Secondly, this study is a cross-sectional study, which limits its ability to capture the dynamic fluctuations in perceived stress, psychological distress, experiential avoidance, and trait mindfulness among HCC patients undergoing TACE. Furthermore, the cross-sectional design does not allow for causal inferences. Future research should consider utilizing a longitudinal study design to confirm causal relations among these variables. Thirdly, it is important to acknowledge that the data in this study were collected through self-reporting, which introduces the potential for reporting bias and recall bias.\u003c/p\u003e\u003ch2\u003e3.2 Clinical implications\u003c/h2\u003e\u003cp\u003eThis study illuminates the pivotal role of perceived stress, experiential avoidance, and trait mindfulness in alleviating psychological distress among HCC patients undergoing TACE. Consequently, trait mindfulness, perceived stress, and experiential avoidance can serve as focal points for mindfulness-based interventions aimed at easing psychological distress. Within such interventions, the perceived stress of HCC patients undergoing TACE can be diminished by incorporating elements of mindfulness-based stress reduction therapy. By integrating components of acceptance and commitment therapy, empirical avoidance can be reduced and trait mindfulness levels increased in HCC patients undergoing TACE, potentially leading to a decrease in their psychological distress. This study offers a theoretical foundation for the development, execution, and elucidation of the mechanisms behind mindfulness-based intervention protocols.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, this study emphasized the importance of experiential avoidance in alleviating psychological stress among HCC patients undergoing TACE, highlighting the pivotal role of dispositional mindfulness. The integration of mindfulness-based interventions and the reduction of experiential avoidance could effectively mitigate psychological stress in HCC patients undergoing TACE.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study received financial support from\u0026nbsp;University Natural Science Research Project of Anhui Provincial\u0026nbsp;[grant number 2023AH050583].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCRediT authorship contribution statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZengxia Liu: Conceptualization, Methodology, Formal analysis, Data curation, Writing -original draft, Writing-review \u0026amp; editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMin Li: Methodology, Data curation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eYong Jia: Data curation, Writing-review \u0026amp; editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLufang Zheng: Data curation, Writing-review \u0026amp; editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLi Chen: Project administration, Supervision.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of competing interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors express their gratitude to all participants and healthcare staff involved in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAkechi, T., et al., 2006. 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Acta Psychiatr Scand. 67 (6), 361-370.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"psychological distress, perceived stress, trait mindfulness, experiential avoidance, hepatocellular carcinoma","lastPublishedDoi":"10.21203/rs.3.rs-5401067/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5401067/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eObjective\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe aim of this study was to explore the moderated mediation mechanism of the relationships among perceived stress, psychological distress, experiential avoidance and trait mindfulness of hepatocellular carcinoma (HCC) patients after transarterial chemoembolization (TACE) in China.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis study utilized a cross-sectional approach to gather data from 458 HCC patients undergoing TACE. Participants completed self-report measures assessing psychological distress, perceived stress, experiential avoidance and trait mindfulness. Mediation and moderation analyses are carried out in SPSS macro PROCESS.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003ePerceived stress could affect psychological distress and experiential avoidance could mediate this relationship(mediation effect\u0026thinsp;=\u0026thinsp;0.041, [95%CI=(0.027, 0.056)]). Trait mindfulness played a role as a moderator in the direct and indirect effect of perceived stress on psychological distress.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eOur findings underscore the vital role of experiential avoidance and trait mindfulness to relieve psychological distress, and provide practical implications for mental health intervention programs of HCC patients undergoing TACE.\u003c/p\u003e","manuscriptTitle":"Effect of perceived stress on psychological distress in hepatocellular carcinoma patients undergoing TACE: the mediating role of experiential avoidance and the moderating role of trait mindfulness","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-09 08:51:59","doi":"10.21203/rs.3.rs-5401067/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-07T18:13:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-07T01:31:08+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-07T01:28:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cancer","date":"2024-11-06T08:37:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"40a18930-0e0a-4d48-b377-72c66906b46a","owner":[],"postedDate":"December 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-02-17T16:05:08+00:00","versionOfRecord":{"articleIdentity":"rs-5401067","link":"https://doi.org/10.1186/s12885-025-13679-y","journal":{"identity":"bmc-cancer","isVorOnly":false,"title":"BMC Cancer"},"publishedOn":"2025-02-13 15:58:12","publishedOnDateReadable":"February 13th, 2025"},"versionCreatedAt":"2024-12-09 08:51:59","video":"","vorDoi":"10.1186/s12885-025-13679-y","vorDoiUrl":"https://doi.org/10.1186/s12885-025-13679-y","workflowStages":[]},"version":"v1","identity":"rs-5401067","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5401067","identity":"rs-5401067","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}