Moderators of an Uncertainty
Management Intervention
For Men With Localized Prostate Cancer
Merle H. Mishel ▼ Barbara B. Germino ▼ Michael Belyea ▼ Janet L. Stewart
Donald E. Bailey, Jr. ▼ James Mohler ▼ Cary Robertson

Background: The effectiveness of psycho-educational inter-
ventions for cancer patients is well documented, but less is
known about moderating characteristics that determine
which subgroups of patients are most likely to benefit.

Objectives: The aim of this study was to determine whether
certain individual characteristics of African-American and
White men with localized prostate cancer moderated the
effects of a psycho-educational Uncertainty Management
Intervention on the outcomes of cancer knowledge and
patient-provider communication.

Methods: Men were blocked by ethnicity and randomly
assigned to one of three conditions: Uncertainty Manage-
ment Intervention provided to the patient only, Uncertainty
Management Intervention supplemented by delivery to the
patient and family member, or usual care. The individual
characteristics explored were education, sources for infor-
mation, and intrinsic and extrinsic religiosity.


Results: Using repeated measures multivariate analysis of
variance, findings indicated that there were no significant
moderator effects for intrinsic religiosity on any of the out-
comes. Lower level of education was a significant moderator
for improvement in cancer knowledge. For the outcome of
patient-provider communication, fewer sources for cancer
information was a significant moderator for the amount told
the patient by the nurse and other staff. Less extrinsic reli-
giosity was a significant moderator for three areas of patient
provider communication. The three areas are the amount (a)
the physician tells the patient; (b) the patient helps with plan-
ning treatment; and (c) the patient tells the physician.

Conclusions: Testing for moderator effects provides important
information regarding beneficiaries of interventions. In the
current study, men’s levels of education, amount of sources
for information, and extrinsic religiosity influenced the effi-
cacy of the Uncertainty Management Intervention on impor-
tant outcomes.

Key Words: moderators • prostate cancer • uncertainty
Nursing Research March/April 2003 Vol 52, No 2
W ith the effectiveness of psycho-educational inter-
ventions for cancer patients well documented
(Meyer & Mark, 1995), the focus has shifted from inter-
vention main effects to concerns about who benefits the
most and on what specific outcomes (Helgeson, Cohen,
Schulz, & Yasko, 2000). The interaction between interven-
tions and patient characteristics changes the question from,
“Does the intervention work?” to, “Does the intervention
work differentially for persons with specific characteristics,
and for which outcomes?” Characteristics that define sub-
groups may moderate the efficacy of an intervention. When
moderator variables significantly interact with treatment,
this indicates that treatment is more effective in the presence
of certain characteristics (Smith & Sechrest, 1991). How-
ever, in order to explain the relationship between treatment,
moderating characteristics, and specific outcomes, modera-
tor variables should be selected based on theory and empir-
ical findings. These are essential for clarifying the change
process and the mechanisms that make an intervention
effective (Shoham-Salomon & Hannah, 1991).
The intervention tested in this study was based on the
theory and previous research on uncertainty in illness,
Merle H. Mishel, PhD, RN, FAAN, is the Kenan Professor of
Nursing, School of Nursing, University of North Carolina at
Chapel Hill.
Barbara B. Germino, PhD, RN, FAAN, is the Blackwell Professor
in Thanatology, School of Nursing, University of North Carolina
at Chapel Hill.
Michael Belyea, PhD, is Research Associate Professor, School of
Nursing, University of North Carolina at Chapel Hill.
Janet L. Stewart, MN, RN, is a doctoral candidate in nursing,
School of Nursing, University of North Carolina at Chapel Hill.
Donald E. Bailey, Jr. PhD, RN, is Assistant Professor, School of
Nursing, Duke University, Durham, North Carolina.
James Mohler, MD, is Research Associate Professor of Surgery
and Pathology, Department of Medicine, University of North
Carolina at Chapel Hill.
Cary Robertson, MD, is an Associate Professor of Urologic
Surgery, Department of Medicine, Duke University, Durham,
North Carolina.
89
90 Moderators of Intervention
which guided the selection of strategies
to improve psychological and behav-
ioral outcomes (Mishel, 1988, 1997).
Uncertainty is a fluctuating experience
that never totally resolves in cancer;
therefore, the purpose of intervention is Moderator variables were
not to eliminate uncertainty, but to
assist patients in managing it.
categorized as intrinsic
This article examines the interac- (personal factors) or
tion of selected theoretically based indi-
extrinsic (contextual
vidual characteristics and the Uncer-
tainty Management Intervention on factors)
treatment outcomes. Data were drawn
from a study that evaluated the effects
of two different approaches to deliver-
ing the Uncertainty Management Inter-
vention to men with localized prostate
cancer (Mishel et al., 2002).
According to the Uncertainty in Illness Theory (Mishel,
1988), main effects or ethnic interaction effects were antic-
ipated for the intervention on the uncertainty management
outcomes of (a) cancer knowledge, (b) problem-solving, (c)
cognitive reframing, (d) patient-provider communication,
and (e) management of treatment side effects. Main effects
were found for the intervention on problem-solving and
cognitive reframing, and ethnic interaction effects were
found for the management of specific treatment side effects
(Mishel et al., 2002). The intervention was beneficial for
both White and African American men who received either
the direct or supplemented intervention. However, there
were no effects on the two important uncertainty manage-
ment strategies of cancer knowledge and improved patient-
provider communication.
Therefore, certain individual characteristics that might
cause men to differentially benefit from the intervention,
particularly in terms of cancer knowledge and patient-
provider communication, were considered. Moderator
variables were categorized as intrinsic (personal factors) or
extrinsic (contextual factors). Personal factors included
education and intrinsic religiosity. Contextual factors
included sources for information and extrinsic religiosity.
The Importance of Selected Moderators
Education
Education level is identified in the Uncertainty Illness The-
ory as a resource that patients may use to improve knowl-
edge about their illness, thus reducing uncertainty. However,
research findings do not provide clear support for the asso-
ciation between educational level and uncertainty (Mishel,
1997). No reported studies have explored the possibility
that level of education explains the benefit from the inter-
vention on cancer knowledge (Helgeson & Cohen, 1996).
Cancer knowledge is one of the best resources for managing
uncertainty about cancer treatment and outcomes (Mishel,
1999). Level of education is a significant predictor of
prostate cancer knowledge; those with more education are
more knowledgeable about cancer signs and symptoms
(Price, Colvin, & Smith, 1993; Robinson, Kessler, &
Naughton, 1991). Cancer patients with more education
have a greater sense of control over illness and fewer feelings
Nursing Research March/April 2003 Vol 52, No 2
of helplessness and insecurity (Goodwin,
Samet, & Hunt, 1996). These findings
would support the expectation that men
with more education would differ from
those with less education in using the
intervention to improve their level of
cancer knowledge.
Sources for Information
Cancer patients cite the need for infor-
mation as a frequent concern and seek-
ing information as the most frequent
method used to cope with uncertainty
(Davison, Degner, & Morgan, 1995).
Patients with more sources for informa-
tion are likely to have a wider network
of resources. Men can use an educa-
tional intervention to build on this base
of resources and to use resources more effectively. The
Uncertainty Management Intervention, therefore, included
training to improve patients’ ability to use existing
resources for decision making about the disease and its
management (Davison & Degner, 1997; Deber, 1994).
Religiosity
According to the Uncertainty in Illness Theory, profes-
sional and social supports help patients (a) clarify the situ-
ation, (b) find meaning for illness events, and (c) provide
an explanatory framework that reduces uncertainty about
illness. Religiosity, both extrinsic and intrinsic, has been a
major source of social support for older cancer patients
and a primary means for dealing with the uncertainties of
cancer (Bourjolly, 1998; Koenig, Larson, & Larson, 2001;
Koenig, Weiner, Peterson, Meador, & Keefe, 1997). Intrin-
sic religiosity refers to a personal relationship with a
Supreme Being that occurs through prayer, with prayer as
the means for a supportive transaction. Intrinsically reli-
gious people cope with the uncertainty of cancer by cogni-
tively reframing the stressful situation and finding meaning
in the experience (Dunkel-Schetter, Feinstein, Taylor, &
Falke, 1992; Jenkins & Pargamet, 1995). With the security
and emotional stability that accompanies higher religiosity,
men with intrinsic religiosity may be more amenable to the
intervention and less distracted by anxiety.
Extrinsic religiosity refers to religious involvement
(e.g., a church community, religious activities) and plays a
major role in coping with illness (Matthews et al., 1998).
The church community provides both a social network for
handling problems, and resources under conditions of a
life-threatening illness (Jenkins & Pargament, 1995). Reli-
gious activity (a resource for social cohesiveness) provides
social support as well as a cognitive framework for lower-
ing distress (Baldacchino & Draper, 2001; McIntosh, Sil-
ver, & Wortman, 1993). The social role of church provides
its greatest effect when patients are dealing with the uncer-
tainty associated with cancer (Musick, Koenig, Hays, &
Cohen, 1998).
Although there is extensive support for religiosity as a
coping method for cancer patients, the interaction of reli-
giosity with psychosocial or psycho-educational interven-
tions to predict cancer knowledge or patient-physician com-
Nursing Research March/April 2003 Vol 52, No 2
munication is understudied. Because reli-
giosity is a major theme among older
men and women it was expected that
those with more religious involvement
have a history of learning from others
and so may be more open to receiving
the information provided by an educa- Participants were African
tional intervention focused on managing American and White men
uncertainty.
The following research question has diagnosed with localized
been addressed: Do personal factors prostate cancer
(education, and intrinsic religiosity),
and contextual factors (extrinsic reli-
giosity and sources for information)
alone and in interaction with time and
time by ethnicity function as modera-
tors in explaining intervention benefit
on specific outcomes (level of cancer
knowledge and on patient-provider communication)?
Methods
Subjects
Eligible participants were African American and White
men diagnosed with localized prostate cancer who were (a)
within 2 weeks after catheter removal following surgical
treatment or (b) within 3 weeks into current radiation ther-
apy. Men eligible for the study had (a) no major cognitive
impairment, (b) no concurrent treatment for another form
of cancer, (c) access to a telephone, (d) an identifiable fam-
ily member willing to participate in the study, and (e)
planned to reside in their current community for 12
months. A detailed description of study recruitment proce-
dures and characteristics of respondents and nonrespon-
dents is provided elsewhere (Mishel et al., 2002).
Design
The design for the study was a 3 ⫻ 2 randomized block,
repeated measures design with 3 levels of intervention
(uncertainty management direct [TD], uncertainty manage-
ment supplemented [TS], and control-usual care [C]) crossed
with 2 levels of ethnicity. Men were blocked on ethnicity and
randomly assigned to treatment or control groups. The men
randomly assigned to the control condition received usual
care, but were offered four intervention calls after complet-
ing the final data collection (White and African American).
Measurement on all outcome variables occurred at baseline
(T1), 4 months postbaseline (T2), and 7 months postbaseline
(T3). Moderator variables were measured at T1. All data
were collected in the patients’ homes.
The 8-week intervention was delivered through weekly
phone calls (M ⫽ 23 minutes) to either the patient (treat-
ment direct) or to the patient and family member individu-
ally (treatment supplemented). Nurse interveners were
matched to the patient and family member by ethnicity and
sex. The telephone-delivered intervention to the family
member was independent from, but simultaneous by week
to the telephone-delivered intervention to the patient in the
treatment supplement group. An assessment was conducted
identifying each subject’s cancer-related concerns, the uncer-
tainty associated with the concern, and the degree of threat
Moderators of Intervention 91
posed by the uncertainty. Based on the
assessment, an intervention was selected
and delivered from a standardized list of
interventions. Interventions included
validating and reinforcing the views and
behaviors of the patient, providing
information, activating resources, teach-
ing symptom management strategies,
structuring expectations, problem-solv-
ing, and teaching assertion techniques
for communicating with healthcare
providers.
Measures
Moderator Variables
Education was measured as years of
schooling.
Intrinsic religiosity was measured by eight items added
to the Multidimensional Health Locus of Control Scale
(MHLC) by Bekhuis et al. (1995) to index belief in God’s
role in one’s health. The item response format was a Likert-
type scale ranging from 1 to 6, with higher scores indicating
a stronger belief. The reliability of the scale with this sample
was higher than the reliability of .81 reported by Bekhuis et
al. (1995) from a multiethnic sample of low-income, South-
ern rural men and women with rheumatic disease. Support
for the validity of the measure was reported by Bekhuis et
al., who found that the measure of intrinsic religiosity cor-
related significantly with the three subscales of the Multidi-
mensional Health Locus of Control Scale.
Extrinsic religiosity was measured by an 11-item scale
reported by Brown and Gary (1987) as an index of partic-
ipation in religious activities. The response format was a
Likert-type scale ranging from 1 to 5 with higher scores
indicative of a higher level of involvement in religious
activities. The reliability for African American men in the
sample was similar to the .88 reported by Brown and Gary
for a sample of urban African American men. Support for
the validity of the scale was reported by Mishel et al.
(1997) who found that uncertainty did not provide as
much emotional distress in men with more religious
involvement.
Sources for information was measured by an investiga-
tor-generated 22-item checklist of sources for information
about prostate cancer and its treatment. Examples include
sources such as surgeon, church, American Cancer Society,
and cancer information groups. The number of sources for
information was summed for a total score. Clinical spe-
cialists in oncology nursing provided support for the con-
tent validity of the checklist.
Outcome Variables
Cancer knowledge was measured by an investigator-devel-
oped list of 20 statements about prostate cancer, its diagno-
sis, treatment, and treatment side effects. Respondents used
a true/false/don’t know response format. For the purpose of
analysis, “don’t knows” were coded as incorrect. Summing
the number of correct answers created a total score.
Patient-provider communication was measured by five
investigator-generated items that asked participants to
92 Moderators of Intervention Nursing Research March/April 2003 Vol 52, No 2

reflect on a typical visit to their health- Results

care provider and report the following:
The sample consisted of 239 men (134
White and 105 African American men).
The amount of information the
This sample size is large enough to
physician provided about their
detect a one-fourth standard deviation
illness and treatment;
difference among the experimental and
The amount of information the nurses
and other treatment staff provided
The study was a 3 ⫻ 2 control groups, between the ethnic
groups, or in the treatment by ethnic
about their illness and treatment; randomized block, group interaction with a power of .80.
The amount the patient told the
repeated measures design The average age of the men in the study
physician about problems with
was 64 (SD ⫽ 6.9). Years of education
treatment;
reported averaged 13.4 years (SD ⫽
The amount the patient told the
4.2). However, since school was often
nurse and other treatment staff
suspended during crop harvests, years
about problems with treatment;
of education is likely inflated. Monthly
The amount the patient helped with
income of the sample was diverse, with
planning treatment.
17% reporting a monthly income of
less than $1,000, 20% with an income
Each item was rated on a 1 to 5 response scale, rang-
of $1,000–2,000, 18% with $2,000–3,000, and the largest
ing from “nothing at all” to “a great deal,” with higher
group (45%) above $3,000.
scores reflecting a greater amount of communication.
The study participants were almost evenly divided by
Factor analysis of the items on the patient provider com-
ethnicity with 56% White and 44% African American.
munication scale resulted in one factor with an eigen-
Using tumor, node, and metastases (TNM) staging classifi-
value greater than one. All items loaded on the factor at
cation, the men were classified as T1 (8%), T2 (61%), and
.50 and above. Cronbach alpha for the total sample was
T3 (27%); 4% did not have staging information available.
.75, .74 for White men and .75 for African American
The majority underwent surgery receiving radical prostate-
men. In this presentation individual items are considered
ctomy (56%), nerve-sparing prostatectomy (23%), and
in the analysis as outcomes because more information is
radiation therapy (21%). On intrinsic religiosity the item
available at the item level on the role of the physician
mean for the sample was 4.4 (SD ⫽ 1.4). Cronbach alpha
and nurse as information providers, and on the role of
for the intrinsic religiosity scale in the sample was .94 for
the patient.
the total sample, .93 for White men and .90 for African
American men. The sample item mean on extrinsic reli-
Data Analysis giosity was 3.6 (SD ⫽ . 8). Internal consistency for this
scale with the sample was Cronbach alpha ⫽ .91 for the
Repeated measures multivariate analysis of variance
total sample, .92 for White men and .90 for African Amer-
(MANOVA) was performed with treatment and ethnicity
ican men. The mean score on sources of information for
as the classification variables and the moderators as con-
this sample was 5.6 (SD ⫽ 3.1). The Kuder-Richardson 20
tinuous variables. Treatment and control groups were
(KD20) for the total scale was .71 and .61 for White men
compared on baseline data to check the randomization
and .78 for African American men, respectively. The KD20
procedure. As a result, preexisting health problems, the
reliability of the cancer knowledge scale for the sample was
only baseline variable with a significant group difference,
.67 and .64 for White men and .73 for African American
was included in all analyses as a covariate.
men, respectively. The moderators of education, extrinsic
Moderator variables were grouped according to
religiosity, intrinsic religiosity, and sources of information
whether they were intrinsic to the person (personal factors)
were only slightly correlated (r ranged from ⫺. 01 to .27),
or extrinsic to the person (contextual factors). Separate
except for extrinsic religiosity and intrinsic religiosity (r ⫽.
MANOVAs were conducted for personal factors (educa-
58) and education and intrinsic religiosity (r ⫽ ⫺. 39).
tion and intrinsic religiosity) and for contextual factors
There were no treatment group differences for any of the
(sources for information and extrinsic religiosity) to deter-
moderating variables.
mine treatment group, ethnic group, and treatment by eth-
nic group interaction effects. To aid in the interpretation of
significant moderators, contrasts were constructed to test Personal Factors
for time differences at distinct levels of the moderator vari- The MANOVA for personal factors indicated that there
able. Whereas regression slopes are typically used to illus- were significant differences over time among the treatment
trate moderator effects for between subjects designs, Judd, groups (Wilks’ Lambda F24, 386 ⫽ 1.76, p ⫽ .02, eta2 ⫽
Kenny, and McClelland (2001) recommend constructing .10). (This eta2 corresponds to somewhere between a
contrasts for within subjects designs. Therefore, estimated medium and large effect size.) Follow-up analyses revealed
outcome variable means at each timepoint were computed that the change in cancer knowledge was modified by edu-
from the regression coefficients generated by the general cation (Wilks’ Lambda F 4,422⫽ 3.05, p ⫽ .02, eta2 ⫽ .03).
linear model for 1 standard deviation above and 1 stan- Both White and African American individuals with low
dard deviation below the moderator mean (Cohen & education (1 SD below the mean) who received the sup-
Cohen, 1983). plemented intervention benefited more than controls with
Nursing Research March/April 2003 Vol 52, No 2 Moderators of Intervention 93

TABLE 1. Estimated Means for Cancer Knowledge by Treatment Group

Computed at One Standard Deviation Above and One Standard
Deviation Below the Mean of Education

Low Education High Education

T1* T2 T3 T1 T2 T3
Control 14.60 14.32 14.66 14.04 15.08 16.87
TD** 14.10 15.06 15.35 15.01 15.93 17.00
TS 13.15 15.50 16.03 15.40 15.95 16.88

*T1 ⫽ baseline; T2 ⫽ 4 months post baseline; T3 ⫽ 7 months post baseline.

**TD ⫽ uncertainty management treatment direct; TS ⫽ uncertainty management treatment supplemented.

a greater increase in cancer knowledge from baseline (T1)
to 4 months postbaseline (T2), (F1, 212 ⫽ 8.88, p ⫽ .003).
(Table 1.) The treatment direct group also improved their
level of cancer knowledge over that of the control group;
the difference was not significant.
Those with higher levels of education (1 SD above the
mean) also gained in cancer knowledge, although they
started with more cancer knowledge than those with less
education; their gain was not as dramatic. There were no
significant differences among the treatment groups in can-
cer knowledge for those with higher education.
Education did not function as a moderator for any of
the patient-provider communication items. Intrinsic reli-
gion (belief in a Supreme Being’s control over health) was
not a moderator of cancer knowledge or patient-provider
communication for any ethnic or treatment groups.
Contextual Factors
The MANOVA for contextual factors indicated that there
were significant differences over time among the treatment
and ethnic groups (Wilks’ Lambda F24, 396 ⫽ 1.90, p ⫽
.007, eta2 ⫽ .10). Follow-up analyses revealed that for sev-
eral patient-provider communication items, sources for
information and extrinsic religiosity were significant mod-
erators of the treatment effect. There were no moderators
for the patient communication item indicating the amount
of information the patient gives the nurse.
There was a significant treatment ⫻ ethnicity ⫻
sources for information effect for the patient-provider
communication item of the amount of information the
nurse gives the patient (Wilks’ Lambda F 6,426 ⫽ 2.74, p ⫽.
01, eta2 ⫽ .04. This eta2 corresponds between a small and
medium effect size). For African Americans with fewer
sources of information (1 SD below the mean), both the
treatment direct group (F1, 214 ⫽ 8.96, p ⫽ .003) and treat-
ment supplemented group (F1, 214 ⫽ 4.81, p ⫽ .03) differed
from the control group from 4 months (T2) to 7 months
postbaseline (T3) in how much the nurse told the patient
(Table 2). There was no significance between group differ-
ences for African American patients who had more sources
for information.
There was a significant treatment ⫻ ethnicity ⫻ extrin-
sic religiosity effect for the patient provider item of the
amount the physician told the patient (Wilks’ Lambda F6,
424 ⫽ 2.77, p ⫽ .01, eta ⫽ .04). For African American
2
patients with lower levels of extrinsic religiosity (1 SD
below the mean), a significant difference was found
between the treatment direct group and both the control
group (F1, 213 ⫽ 4.33, p ⫽ .04) and the treatment supple-
mented group (F1, 213 ⫽ 15.17, p ⬍ .0001) in the amount

TABLE 2. Estimated Means for How Much the Nurse Tells the Patient by
Treatment Group Computed at One Standard Deviation Above and
One Standard Deviation Below the Mean of Sources for Information
for African American Subjects

Low Sources of Information High Sources for Information

T1* T2 T3 T1 T2 T3
Control 2.69 2.95 2.29 3.16 3.23 3.56
TD** 2.83 2.30 2.99 3.76 3.48 3.11
TS 2.88 2.20 2.62 3.18 3.84 3.17

*T1 ⫽ baseline; T2 ⫽ 4 months post baseline; T3 ⫽ 7 months post baseline.

**TD ⫽ uncertainty management treatment direct; TS ⫽ uncertainty management treatment supplemented.
94 Moderators of Intervention
TABLE 3. Estimated Means for How Much the Doctor Tells the Patient by
Treatment Group Computed at One Standard Deviation Above and
One Standard Deviation Below the Mean of Extrinsic Religiosity for
African American Subjects
Low Extrinsic Religiosity
T1* T2
Control 4.39 4.16
TD 4.35 3.87
TS 4.01 5.02
Note. T1 ⫽ baseline; T2 ⫽ 4 months postbaseline; T3 ⫽ 7 months postbaseline; TD ⫽ uncertainty management
treatment direct; TS ⫽ uncertainty management treatment supplemented.
the physician told the patient from 4 months to 7 months
postbaseline (Table 3). In contrast, African American men
with higher levels of extrinsic religiosity did not benefit
from the intervention, whereas control patients with higher
levels of extrinsic religiosity gained in receiving informa-
tion during the same interval (F1, 213 ⫽ 4.24, p ⫽ .04)
The treatment effect for the patient-provider communi-
cation items of the amount the patient helped with planning
treatment (Wilks’ Lambda F4, 422 ⫽ 3.02, p ⫽ .02, eta2 ⫽
.03) and the amount of information the patient told the
physician (Wilks’ Lambda F4, 422 ⫽ 3.44, p ⫽ .01, eta2 ⫽
.03) were also modified by extrinsic religiosity. Compared
to those in the control group, patients who had lower lev-
els of extrinsic religiosity and were assigned to either the
treatment direct or treatment supplemented group
improved from baseline to 4 months in the amount they
helped with planning treatment (F1, 212 ⫽ 5.34, p ⫽ .02)
and (F1, 212 ⫽ 4.15, p ⫽ .04) respectively (Table 4). Patients
with higher levels of extrinsic religiosity did not evidence
significant benefit from the intervention on participation in
planning treatment. Treatment patients’ scores remained
low over time, whereas control patients improved from
baseline to 4 months (F1, 212 ⫽ 5.68, p ⫽ .02).
Lower levels of extrinsic religiosity also benefited men
on an additional aspect of patient-provider communica-
tion. There was a significant difference from baseline to 7
months postbaseline for the treatment direct versus both
the control group (F1, 212 ⫽ 9.49, p ⫽ .002) and the treat-
ment supplemented group (F1, 212 ⫽ 7.15, p ⫽ .008) on the
amount the patient told the physician. (Table 5) Regardless
of ethnicity, men in the treatment direct group with lower
levels of extrinsic religiosity were helped by the interven-
tion to communicate more information to their physician.
Discussion
Education as a Moderator
The finding that men with less education benefited from
the intervention by increasing their knowledge about
prostate cancer is a critical finding since poor education is
disadvantageous in managing the side effects from treat-
ment. Cancer patients with less education distance them-
Nursing Research March/April 2003 Vol 52, No 2
High Extrinsic Religiosity
T3 T1 T2 T3
4.08 3.83 4.20 4.79
4.91 4.34 4.21 4.13
3.25 4.07 3.94 4.25
selves from their situation and cope by avoiding instead of
managing the situation (Dunkel-Schetter et al., 1992). The
benefits from improved knowledge are numerous includ-
ing (a) improved adherence to and follow-up on recom-
mendations, (b) greater performance of preventive health
behavior, and (c) improved ability to gain information
from physicians (Meyerowitz, Richardson, Hudson &
Leedham, 1998).
These findings support those of others who have
reported that educational interventions can improve
knowledge in those with less education (Helgeson &
Cohen, 1996). However, traditional educational interven-
tions that require reading may be less attractive to men
with lower levels of education. Interventions given over the
telephone may be a more appropriate avenue for providing
information to those with less education.
It is clear that men with less education entered the
intervention with less knowledge about prostate cancer
than did more highly educated men. Men with more edu-
cation gained knowledge from the experience of dealing
with prostate cancer over time. However, men with less
education used the education provided by the intervention
to learn the content that lead to improvements in cancer
knowledge. Targeting special population groups (e.g.,
those with low education) and providing educational inter-
ventions that improve knowledge removes one of the bar-
riers that cause less educated individuals to be more sus-
ceptible to a downward trajectory in their illness.
Sources for Information as a Moderator
African American men with fewer sources for information
did not show an initial benefit from the intervention in
their ability to communicate with healthcare providers.
Eventually, they were able to use the skills from the inter-
vention to gain information from the nurse and other treat-
ment staff. However, the scores for those with fewer
sources for information remained below those of men with
high sources of information. It is likely that men use the
information sources provided in the intervention as
resources for generating questions, resulting in more com-
munication with the treatment staff. Low sources for infor-
mation is a characteristic of the population that can bene-
Nursing Research March/April 2003 Vol 52, No 2 Moderators of Intervention 95

TABLE 4. Estimated Means for How Much the Patient Helps

With Planning by Treatment Group Computed at One Standard
Deviation Above and One Standard Deviation Below the Mean of
Extrinsic Religiosity

Low Extrinsic Religiosity High Extrinsic Religiosity

T1 T2 T3 T1 T2 T3
Control 3.42 3.13 3.15 2.92 3.65 3.25
TD 2.75 3.65 3.72 3.24 3.31 3.44
TS 3.45 4.36 3.79 3.21 2.84 3.18

Note. T1 ⫽ baseline; T2 ⫽ 4 months postbaseline; T3 ⫽ 7 months postbaseline; TD ⫽ uncertainty management

treatment direct; TS ⫽ uncertainty management treatment supplemented.

fit substantially from the intervention to improve their
communication with healthcare providers.
Extrinsic Religiosity as a Moderator
Low levels of extrinsic religiosity was a significant moder-
ator of intervention effectiveness in three areas of patient-
provider communication: how much information the
patient tells the physician, how much the patient helps in
planning treatment, and how much information the physi-
cian shares with the patient. These findings are in contrast
to those who reported more involvement in religious activ-
ities. Among the latter, control subjects improved over
both treatment groups on two of these three patient-
provider communication outcomes. One possible explana-
tion for these findings is that men with more religious par-
ticipation have a network of supportive others to whom
they may turn instead of using the intervention. The ques-
tion is whether religious participation is a help or a hin-
drance in using the intervention to improve communica-
tion with the physician. Since the physician has been
identified as a primary source of information, being able to
use the intervention to enhance communication skills is
important in managing the uncertainty surrounding treat-
ment and treatment side effects (Davison & Degner, 1997;
Wells, McQuellon, Hinkle, & Cruz, 1995).
Social resources, attributed to religious activities, may
prevent some men from benefiting from the intervention in
their communication with the physician. In the interven-
tion, when an uncertainty is identified and the intervener
provides the man with strategies for communicating with
the healthcare provider to resolve the uncertainty, men
with higher levels of religious participation may choose to
ignore this aspect of the intervention and use church-based
and religion-based support networks. These supportive
persons may provide their own advice about managing the
uncertainty and, in doing so, weaken the impact of the
intervention. The potential discrepancy between the per-
spective of the existing religion-based network and the per-
spective in the intervention resulted in little or no move-
ment in the ability to communicate with the healthcare
provider for those with high levels of religious participa-
tion. In contrast, men with less participation in religious
activity did not necessarily choose between using the
church-based and religion-based network or the interven-
tion, and were, therefore, amenable to learning the strate-
gies for communication.
There are some limitations to these findings. First, the
results are limited to 7 months after medical treatment.
Longer follow-up would be beneficial. Many interventions
may claim short-term effects only to discover that these

TABLE 5. Estimated Means for How Much the Patient Tells the Doctor
by Treatment Group Computed at One Standard Deviation Above and
One Standard Deviation Below the Mean of Extrinsic Religiosity

Low Extrinsic Religiosity High Extrinsic Religiosity

T1 T2 T3 T1 T2 T3
Control 4.04 4.33 4.06 3.82 4.27 4.23
TD 3.45 4.29 4.63 4.11 4.32 4.03
TS 4.01 4.44 3.91 4.15 4.31 4.39

T1 ⫽ baseline; T2 ⫽ 4 months postbaseline; T3 ⫽ 7 months postbaseline; TD ⫽ uncertainty management treat-

ment direct; TS ⫽ uncertainty management treatment supplemented.
96 Moderators of Intervention
effects disappear over time. For the intrinsic religiosity
variable, there were no significant moderator effects. How-
ever, other studies have shown that intrinsic religiosity is
very significant in reducing depression and other negative
mood states. Since these were not the outcomes of interest,
the moderating effect of intrinsic religiosity on the inter-
vention needs to be further explored (Fehring, Miller, &
Shaw, 1997; Koenig et al., 1997).
These findings suggest that low levels of religious par-
ticipation facilitate benefiting from the intervention, when
communicating with the healthcare provider is the out-
come. However, the level of religious participation did not
influence cancer knowledge or communicating with the
nurse. It is clearly tied to talking with the physician. Since
many older men in the South are highly involved in their
religious communities, it is important that educational
interventions include strategies for incorporating religious
community values and beliefs into the intervention.
Patient-physician communication is so very important in
managing illness and educational interventions need to be
applicable to cancer patients who seek their social support
in religion-oriented activities. ▼
Accepted for publication December 9, 2002.
This study was supported by a research grant from the National Can-
cer Institutes and the National Institute of Nursing Research (Manag-
ing Uncertainty in Stage B Prostate Cancer, R01 NR/CA03782, Dr. M.
Mishel, P.I.).
The authors thank the following individuals: Dr. Lorna Harris for her
contribution towards minority recruitment; Drs. David Paulson, Paul
Godley, and Mitchell Anscher for facilitating subject recruitment;
Andrea Ware and Sheron Sumner, project managers; and Robert
Ahmed, Kay Gruninger, Richard Kelsey, Joe Sanders, Lynn Scallion,
Sheila Tedder, James Trogdon, and Howard Williams, nurse interven-
tionists.
Corresponding author: Merle H. Mishel, PhD, Carrington Hall,
School of Nursing, University of North Carolina, Chapel Hill,
NC27599-7460 (e-mail: mishel@email.unc.edu)
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