European Journal of Oncology Nursing 18 (2014) 52e57

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European Journal of Oncology Nursing

journal homepage: www.elsevier.com/locate/ejon

Psychometric properties of the Persian version of the Mishel’s

Uncertainty in Illness Scale in Patients with Cancer
Moosa Sajjadi a, b, Maryam Rassouli a, c, *, Abbas Abbaszadeh d, Hamid Alavi Majd e,
Kazem Zendehdel f
a
Nursing & Midwifery School, Shahid Beheshti University of Medical Sciences, Tehran, Iran
b
Gonabad University of Medical Sciences, Gonabad, Iran
c
Pediatric Nursing Department, Nursing & Midwifery School, Shahid Beheshti University of Medical Sciences, Vali-e Asr Street, Niyayesh Cross, Tehran, Iran
d
Department of Nursing, Nursing & Midwifery School, Shahid Beheshti University of Medical Sciences, Tehran, Iran
e
Department of Biostatistics, School of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
f
Cancer Research Center, Cancer Institute of Iran, Tehran University of Medical Sciences, Tehran, Iran

a b s t r a c t
Keywords: Purpose: Uncertainty is a major component in the illness experiences which extraordinarily can affect
Uncertainty in illness the psychological adjustment and the illness outcomes. Uncertainty in illness is defined as inability to
MUIS-A
define the illness-related events to the illness or disability in predicting the illness outcomes. The present
Psychometrics
Cancer
study aimed to translate the Persian version of Uncertainty in Illness Scale (MUIS-A) and to investigate its
Confirmatory factor analysis psychometric properties on patients with cancer.
Method: In this methodological study, validation of the Persian version of MUIS-A was performed in Iran
on 420 cancer patients attending two major hospitals in Tehran, Iran. The scale was translated into
Persian and back translated into English and revised according to editorial comments of the scale de-
signers. Then, content and face validity, construct validity, internal consistency reliability and stability of
the Persian version were measured. Data were analyzed using SPSS version 16 and LISREL 8.5.
Results: Mean of the participants MUIS-A score was 90.1 (16.8). Confirmatory factor analysis confirmed
validity of the whole instrument and its four subscales. The consistency of the instrument with a three-
week interval was r ¼ 0.91. Cronbach’s alpha was 0.89 for the whole scale of 32 MUIS-A items and
a ¼ 0.58e0.86 for its four factors.
Conclusions: The Persian version of the MUIS-A has good psychometric properties. It can be used to
assess uncertainty in illness in Iranian patients with cancer.
Ó 2013 Elsevier Ltd. All rights reserved.

Introduction
Uncertainty is a natural part in the illness experience and can
occur at all stages of disease including diagnosis, treatment and
prognosis of the disease. Uncertainty in illness occurs when the
patient is unable to determine the meaning of illness-related
events; therefore, it is considered a major cause of psychological
stress to the patients (Mishel, 1997a, 2013), that can leave major
impacts on the psychological adaptation and outcomes of the dis-
ease (Neville, 2003). Uncertainty in illness is defined as the
“inability to determine the meaning of illness-related events when
* Corresponding author. Pediatric Nursing Department, Nursing & Midwifery
School, Shahid Beheshti University of Medical Sciences, Vali-e Asr Street, Niyayesh
Cross, Tehran, Iran. Tel.: þ98 21 88655372; fax: þ98 21 88202521.
E-mail address: Rassouli.m@gmail.com (M. Rassouli).
the patient cannot determine the value of events or cannot accu-
rately predict the disease outcome due to the lack of sufficient cues”
(Mishel, 1988).
Uncertainty occurs when the individuals cannot form a cogni-
tive framework for understanding their status and interpreting
illness related events (Bailey et al., 2011; Mishel, 1990, 2013).
Therefore, in most cases, it is accepted as a major stressor that most
people seek to reduce and to learn methods to cope with (Neville,
2003). Chronic diseases are a long term and intense source of
psychological stress that influences all aspects of patients’ life and
reduces their daily activities and quality of life (Flemme et al.,
2005). Furthermore, various studies have been conducted on
chronic patients such as patients with cardiovascular diseases,
dialysis, hepatitis, liver transplantation, AIDS and Alzheimer’s
whose results indicate that uncertainty exists in these patients and
can lead to reduction in quality of life and the ability to cope with

1462-3889/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ejon.2013.09.006
 M. Sajjadi et al. / European Journal of Oncology Nursing 18 (2014) 52e57
illness (Bailey et al., 2009; Brashers et al., 2004; Flemme et al.,
2005; Lasker et al., 2010; Madar and Bar-Tal, 2009; Mauro, 2010;
Sodowsky, 2012).
Cancer, as one of the chronic diseases, is the second leading cause
of death in the West (Shaha et al., 2008). It is the third cause of death
in Iran after heart diseases and car accidents. Based on the recent
statistics, the rate of cancer incidence in Iran is about 107 people in
100,000 people (more than 80,000 people considering Iran’s 75-
million population). It is predicted that with regard to the raise of
environmental pollution, increasing the elderly (aging community)
and population growth, coming decades will witness an increasing
trend in cancer so that it becomes a principle health problem in Iran
(Rasaf et al., 2012). Today, advances in cancer diagnosis and treat-
ment technology has led to an increase in patients’ survival, and one
of the important points in the care of these patients is to notice and
improve the quality of life (Stewart et al., 2010b).
From the diagnosis time to the onset of treatment, patients with
cancer suffer from high levels of emotional tension (Chen et al.,
2010). Due to the complexities of treatment and symptoms, pa-
tients experience some levels of uncertainty about illness which
originates from problems related to the inability to perform daily
activities, inadequate treatment, and concerns about the relapse of
the disease (Haisfield-Wolfe et al., 2012). Various studies have been
conducted in the field of uncertainty in illness in different types of
cancer in other countries (mainly Western countries) (Detprapon
et al., 2013; Haisfield-Wolfe et al., 2012; Harrow et al., 2008; Kur-
ita et al., 2013; Parker et al., 2013; Shaha et al., 2008; Sherman and
Simonton, 2010; Stewart et al., 2010a; Woodgate and Degner,
2002). The ultimate goal of these studies is to help the patients (or
their families) to effectively manage uncertainty so that its negative
effect on the patient’s psychological adaptation is reduced (Stewart
et al., 2010b). Nurses are frequently in contact with the patient, thus
they are in the best position to reduce uncertainty in patients by
providing information and promoting patients’ understanding of
health (Madar and Bar-Tal, 2009).
In order to conduct interventions to reduce uncertainty in patients
with cancer and to measure effectiveness of these interventions, a
scale is needed to measure it. There are various scales for uncertainty
assessment in different patients and groups (Lin et al., 2012; Mishel,
1997b; Pai et al., 2007; Stewart et al., 2010a). One of the convenient
and widely used scales is Mishel Uncertainty in Illness Scale-Adult
form (MUIS-A). MUIS-A is a valid and reliable scale and has been
used in several studies. This instrument contains 32 items on Likert
scale from 1 (strongly disagree) to 5 (strongly agree) points and oc-
curs in four dimensions of ambiguity, complexity, inconsistency, and
unpredictability. The instrument scores between 32 and 160, and
earning more points shows greater uncertainty (Bailey et al., 2009;
Mishel, 1997b). MUIS-A has a good internal consistency with Coro-
nbach’s alpha of 0.87 for the whole instrument, 0.86 for the subscales
of ambiguity (13 items), 0.81 for complexity (7 items), 0.78 for
inconsistency (7 items), and 0.65 for unpredictability (5 items). This
scale has been translated into different languages and its validity and
reliability have been studied (Mishel, 1997b).
Despite the importance of the concept of uncertainty in illness
in cancer patients, no valid and reliable tool exists in this regard in
Iran. Therefore, this study was conducted with the aim of trans-
lation and psychometric properties of the Persian Version of
“Mishel Uncertainty in Illness Scale” in cancer patients.
Methods
Procedures
The present study is a methodological research (LoBiondo-
Wood et al., 2006) through which the MUIS-A scale is translated
53
and its Persian version has been validated among patients with
cancer. The study population was all the cancer patients attending
the clinics and oncology wards of Imam Khomeini Hospital (Iran’s
largest cancer center) and Taleghani Hospital in Tehran. Given
these centers accept patients from all over the country, results of
the study can be better generalized to the society. Convenient
sampling was performed in order to achieve a sufficient sample
size to conduct a confirmatory factor analysis. The inclusion
criteria were willingness to participate in research, cancer diag-
nosis by the oncologist, being aware of one’s illness, being Iranian,
the ability to understand and speak Persian, the minimum age of
21 years, and absence of other serious illnesses and no history of
serious mental disorders (such as schizophrenia). Type and stage
of cancer and treatment type were not the inclusion criteria of this
study. Based on these criteria, eventually 420 individuals were
chosen.
Scale translation
In this study, translation and validation of the instrument was
performed based on the suggested model by Wild et al. (2005).
After obtaining written permission from the original designer of the
scale, the original scale was translated into Persian by two people
fluent in English and Persian. Then the two translations were
compared and the final version was prepared with a few modifi-
cations. Then, the final translated version was given to two people
fluent in both languages of English and Persian (one native English
speaker), who were not in contact with the first people to translate
it back into English. Then, the back-translation was contrasted by a
supervisor with translations of the original scale in terms of simi-
larity of translations, and some minor revisions were made in
statements of the Persian version. Afterward, validation process of
the translated scale was performed by assessing face and content
validity, construct validity (using confirmatory factor analysis),
reliability, and internal consistency.
Content validity
In order to examine the content validity index (CVI), the
translated scale was given to ten people (a specialist in clinical
psychology, an oncologist, two psychiatric nurses, two oncology
nursing instructors, four nursing assistant professors with
experience in instrument development) to review that and
provide their correctional comments. They also investigated and
affirmed face validity of the translated scale. Then, the scale was
given to 10 patients with cancer to express their idea about
simplicity of use, and understandability of words and phrases.
The Persian version was finalized without much change in its
sentences.
Data collection
To collect the data, after choosing eligible patients and
explaining the study objectives and methods, the informed consent
was obtained from them. Next, the questionnaire including de-
mographics (age, sex, educational level, marital status, occupation,
place of residence, type of illness, type of treatment, time of diag-
nosis) and MUIS-A scale were given to them to complete.
Completion of the questionnaire took about 20e25 min. For illit-
erate people, the questionnaire was read and patients’ answers
were marked by the researcher. Investigating validity of the MUIS-A
construct and the model fitness was conducted by confirmatory
factor analysis (CFA) using LISREL statistical software version 8.5.
54 M. Sajjadi et al. / European Journal of Oncology Nursing 18 (2014) 52e57

Construct validity
CFA is a structural equation modeling technique which is used to
determine the goodness of fit between a hypothesized model and
the data obtained from study samples (Kline, 2010). Maximum
likelihood algorithm was used to evaluate the fitness of the model.
There are several fit indices for deciding on the goodness of fit of
the model and it is recommended that different indices be used
(Brown, 2006; Seo et al., 2004). In this study, indices of fit chi-
square, root mean error of approximation (RMSEA), goodness-of-
fit index (GFI), comparative fit index (CFI), adjusted goodness-of-fit
index (AGFI), and standardized root mean square residual (SRMR)
were used. One of the most used indexes is chi-square. Because this
index is related to the sample size, ratio of chi-square to degrees of
freedom is used, where values less than 2 indicate a good fit of the
model. Another important index is the RMSEA, where values less
than 0.08 are acceptable and less than 0.05 indicates good fit of the
model. Researchers are advised to report the confidence interval
(Kline, 2010; Seo et al., 2004). Another important index is SRMR,
whose acceptable value is 0.06 or less (Brown, 2006; Kline, 2010).
Appropriate values are >0.9 for CFI and GFI, and >0.85 AGFI
(Bentler, 1990; Helsen et al., 2013).
Reliability
Internal consistency and reliability were measured using SPSS
software version 16. Scale internal consistency was measured by
Cronbach’s alpha for the total scale and each subscale separately.
The best method used to evaluate the internal consistency is
Cronbach’s alpha (Polit and Beck, 2013). The Cronbach’s alpha of
about 0.7 is sufficient, and of >0.80 indicates high internal con-
sistency of the tool (Polit and Beck, 2013). The reliability was
measured by Pearson’s or Spearman’s correlation coefficients in
testeretest on 15 patients with a three-week interval. Usually, the
time interval of 2e3 weeks is appropriate between two tests
(Hawthorne et al., 2011; Polit and Beck, 2013).
Results
A total of 420 questionnaires were analyzed. Demographic
characteristics of the study sample are shown in Table 1. Content
validity index was measured on relevance, clarity, and simplicity of
the translated scale as 0.98, 0.95, and 0.96, respectively.
Table 2 shows mean and standard deviation of the overall scores
of MUIS-A and its dimensions. In order to have a better comparison
between the present scale and the original one, data of the present
study were compared to the combined multiple studies on patients
with cancer (Mishel, 1997b). The results show that mean of the
overall score of uncertainty in illness in the present study (90.1) is
greater than that of the combined sample of cancer patients pro-
posed by Mishel (79.5). Coefficient of Cronbach’s alpha was 0.89 for
the overall scale, and 0.58e0.86 for its dimensions (Table 2). The
correlation coefficient testeretest reliability for MUIS-A was 0.91
(p < 0.001). Correlation coefficients for subscales of ambiguity,
complexity, inconsistency, and unpredictability were respectively
0.90, 0.74, 0.83, and 0.60.

Table 1
Demographic and clinical characteristics of patients with cancer (n ¼ 420).

Mean SD (range)

Age (year) 46.4 13.9 (21e79)

Time since diagnosis (months) 18.5 24.2 (3e168)

N %

Sex Female 217 51.7

Male 203 48.3
Marital status Single 58 13.8
Married 331 78.8
Widowed or divorced 31 7.3
Education level Illiterate 87 20.7
Primary and Guidance school 151 36
Diploma 107 25.5
University degree 75 17.9
Occupation Self-employed 76 18.1
Employee 34 8.1
Housewife 174 41.4
Unemployed 35 8.3
Other 103 24.1
Time since diagnosis (months) <6 166 39.5
6e24 163 38.8
>24 91 21.7
Type of cancer Breast 103 24.5
Colon and rectum 99 23.6
Gastric/esophagus 36 8.6
Hematologic 72 17.1
Uterus/ovarian 25 6
Prostate 5 1.2
Lung 21 5
Skin 5 1.2
Other 54 12.9
Metastasis Yes 143 36.3
No 251 63.7
Kind of treatment Chemotherapy 105 25
Chemotherapy and surgery 189 45
Chemo and radiotherapy 26 6.2
All of them 90 21.4
Other 10 2.4
 M. Sajjadi et al. / European Journal of Oncology Nursing 18 (2014) 52e57 55

Table 2
Scores for MUIS-A scale and its dimensions in Iranian patients with cancer and it’s comparison with Mishel’s data bank.

Ambiguity Complexity Inconsistency Unpredictability Total mean (SD) e a

mean (SD) e a mean (SD) e a mean (SD) e a mean (SD) e a

Iranian patients 41.8 (9.4)e0.86 15.1 (3.2)e0.58 18.8 (4.2)e0.71 14.4 (3.5)e0.65 90.1 (16.8)e0.89
with cancer (N ¼ 420)
Mishel’s combined data 32.3 (9.3)e0.87 16.5 (5)e0.80 14.9 (4.7)e0.80 15.8 (3.7)e0.67 79.5 (16.9)e0.90
for cancer patients (N ¼ 761)

Construct validity
To investigate construct validity and provide the most appro-
priate model for the MUIS-A, confirmatory factor analysis was used.
To this end, full samples of cases were randomly split into two
approximately equal groups. 200 subjects were considered as
calibration sample and 220 subjects were considered as evaluation
sample. Calibration samples were used to check the models (2 and
4 factors) and do possible revisions. Evaluation sample was used to
validate the appropriate model. Two-dimensional model of the
scale did not have good fit indices, but the four-dimensional model
had better fit indices. The chi-square, RMSEA, SRMR and AGFI
indices confirm the fit indices of the model (Table 3). By assessing
the scale items, it was determined that the item 32 “The serious-
ness of my illness has been determined” had a weak item-scale
correlation coefficient (r ¼ 0.02), therefore, item 32 was removed.
According to the suggestion of modification of fit indices in
confirmatory factor analysis, transferring item 8 “I do not know
when to expect things will be done to me” (from the ambiguity to
the inconsistency) and item 28 “treatment which is being done to
me has a known probability of success” (from the complexity to the
unpredictability) improved the fit of the model. Therefore, the four-
dimensional model of MUIS-A with 31 items (ambiguity 12 items,
complexity 5 items, inconsistency 8 items and unpredictability 6
items) is a model with the best fit indices. CFI and GFI indices are
acceptable (Bentler, 1990) and other indices such as the ratio of chi-
square to degree of freedom, RMSEA, AGFI and SRMR indicate a
good fit of the model (Brown, 2006; Helsen et al., 2013; Kline,
2010).
In order to further investigate validity of the construct, the
relationship between education level and uncertainty in illness rate
was used. In this study, a strong inverse correlation was found
between uncertainty and the level of education (r ¼ 0.47,
p < 0.001) in the sense that patients with higher level of education
had less uncertainty.
Discussion
Uncertainty in illness is a concept that can have broad impact on
cancer patients and its investigation in this group of patients is of
great importance. Despite the importance of the issue, this problem
has not been studied in Iran that can be attributed to lack of proper
tools in Iran. Therefore, this study was conducted with the aim of
translating and validating the Persian version of the uncertainty in
illness scale in patients with cancer. In this study, the MUIS-A scale
was translated into Persian and its psychometric properties and
factor structure were evaluated. When a tool is translated or used in
another culture or society, it is essential to evaluate its psycho-
metric properties because that may not be appropriate in the new
society (Hillen et al., 2013; Michaeli Manee, 2011). In this study,
content validity, construct validity, and reliability of this tool were
assessed.
Based on the findings, the Persian version of MUIS-A generally
has good reliability and validity and its dimensions’ construct is
similar to that of the original one (Mishel, 1997b). In this study, it
has been shown that with regard to content validity index of 0.96,
the Persian version of MUIS-A has a good content validity. Polit and
Beck (2013) suggest that the CVI value of 0.9 or more should be
considered as a standard for content validity of the scales (Polit and
Beck, 2013).
Confirmatory factor analysis of MUIS-A was conducted using a
sample of 420 cancer patients. Goodness-of-fit indices indicated
that the original model (32-item and 4-dimensional) of Persian
version of the uncertainty in illness scale is appropriate, but for
better fit indices and to enhance the fit indices some changes are
needed to be made in the original scale. In confirmatory factor
analysis, some suggestions are given by Lisrel to modify and
improve the model fit indices. If they are justifiable logically and
theoretically, they can be applied (Kline, 2010). In the Persian
version, item 32 “The seriousness of my illness has been deter-
mined” from complexity dimension was deleted due to its low
correlation coefficient of item-scale.
In validation of the Swedish version of this scale for the cardiac
patients, it was indicated that this item has no significant corre-
lation with the overall score of the scale and complexity subscale.
Furthermore, items 10 and 22 were excluded from the Swedish
version (Hallberg and Erlandsson, 1991). Another study was con-
ducted in Iran to validate the scale of uncertainty in illness e
family form. This scale assesses uncertainty from patients’ family’s
perspective. The original version of this scale has 31 items and is

Table 3
Confirmatory Factor analysis Fit indices for the different MUIS-A version in Iranian patients with cancer.

c2 (df), p RMSEAc (90% CI) CFId GFIe AGFIf SRMRg

MUIS-A, 2 factorsa 657.4 (349), p < 0.001 0.067 (0.059e0.074) 0.76 0.81 0.78 0.071
MUIS-A, 4 factorsa (original) 767.4 (458), p < 0.001 0.054 (0.048e0.060) 0.87 0.90 0.88 0.063
MUIS-A, 4 factorsa (modified) 660.7 (428), p < 0.001 0.047 (0.040e0.054) 0.91 0.92 0.90 0.048
MUIS-A, 4 factorsb (modified) 652.3 (428), p < 0.001 0.049 (0.044e0.054) 0.91 0.93 0.91 0.046
a
Calibration sample (N ¼ 200).
b
Validation sample (n ¼ 220).
c
Root mean error of approximation.
d
Comparative fit index.
e
Goodness-of-fit index.
g
Standardized root mean square residual.
f
Adjusted goodness-of-fit index.
56 M. Sajjadi et al. / European Journal of Oncology Nursing 18 (2014) 52e57
one-dimensional. In psychometric properties of this scale applied
for 310 family members of patients hospitalized in the ICU, it was
shown that 5 items were not appropriate and had to be removed.
Content and convergent validity and reliability of the Persian
version of the scale was confirmed in the form of a 26-item scale.
However, in this study, construct validity and subscales of this tool
were not assessed by factor analysis (Vagharseyyedin and Vanaki,
2011). Another study was performed by Pai et al. (2007) on the
psychometrics of the uncertainty scale in pediatric patients
(CUIS). This scale is the adjusted form of Mishel’s Uncertainty in
Illness Scale-Community Form (MUIS-C). By conducting a sepa-
rate exploratory and confirmatory factor analysis on 373 children
with chronic illnesses, 8 items were removed from 23 items of the
original instrument. The new scale with 14 items and two di-
mensions received very good fit for this group of patients.
Removing item 8 “I know everything about my disease” was rec-
ommended by the CFA, which logically would be acceptable
because children could not understand everything about their
illness (Pai et al., 2007). Nevertheless, in our opinion, its low item-
total correlation coefficient in the Persian version seems to be
more related to the sample of the study because all subjects, ac-
cording to the inclusion criteria, were aware of their cancer, so
almost all of them had agreeably answered this question. This
probably would be a good item for the patients in the process of
cancer diagnosis.
In the Persian version, item 8 of the ambiguity dimension “I do
not know when to expect things will be done to me” was trans-
ferred to the inconsistency dimension. Furthermore, item 28
“treatment which is being done to me has a known probability of
success” was transferred from the complexity dimension to the
unpredictability dimension.
Factor structure in the original scale was shown changeable in
analyses conducted by Mishel at different times, in the sense that
some items were transferred from one factor to another (Mishel,
1997b). Findings obtained by Pai et al. (2007) showed that in the
validated scale of uncertainty in pediatric patients, some items of
the original scale can be placed within another factor (Pai et al.,
2007).
In another study that conducted the psychometric properties of
this scale for patients with brain tumors, some items of complexity
and ambiguity were transferred to other factors (Lin et al., 2012).
Other studies also have been conducted on the validation of the
same scale whose findings showed that the scale items can be
transferred from one factor to the next (Helsen et al., 2013; Hillen
et al., 2013).
Transfer of these items theoretically and logically has no
obstacle and Mishel herself has integrated some of them in the
two dimensional MUIS scale. Another reason may be that Iranian
patients are not able to differentiate among sense of ambiguity,
complexity, and unpredictability. Therefore, it is proposed a
qualitative research be conducted to infer the sense of uncer-
tainty and its dimensions among the Iranian patients with
cancer.
According to the theory of uncertainty in illness, a negative and
significant relationship should be between the education level and
score of uncertainty in illness, which has been confirmed in many
studies (Mishel, 2013). In this study, a strong and inverse rela-
tionship was found between education level and uncertainty in
illness so as education level increases in them, the level of uncer-
tainty decreases. Furthermore, this finding confirms the construct
validity of this scale.
Findings of the present study show that mean and standard
deviation of the scores of uncertainty in illness scale and its di-
mensions are very similar to its values in the combined sample of
the patients with cancer investigated by Mishel (Mishel, 1997b).
This issue itself also can be an approval of the Persian version
validity of this scale and its dimensions. The score of uncertainty in
illness in our study was higher. This finding can be justified by
lower level of patients’ education and knowledge in our society.
The results of the present study showed that the Persian scale of
MUIS-A has a good internal consistency. In the present study, the
overall Cronbach’s alpha of this scale and its dimensions is close to
the obtained values in the combined sample of cancer patients,
conducted using the original scale. Two dimensions of the scale
have an acceptable internal consistency. Lower alpha in some di-
mensions is because of its low number of items. For example, the
relatively low Cronbach’s alpha in complexity dimension (0.58) can
be attributed to the fact that 7 items in the original scale reduced to
5 items in the Persian version. Nevertheless, the obtained alpha for
various aspects of this study is close to that in some studies re-
ported by Mishel (Mishel, 1997b). The ambiguity dimension, with
regard to its high internal consistency and its high correlation with
the whole scale (p < 0.001, r ¼ 0.93), can be used alone, but it is
better to use the whole instrument in the study. In addition to the
internal consistency, results of the testeretest showed that the
Persian version of this scale has a good stability.
Limitations
The present study had some limitations. First, about 21% of the
samples were illiterate, and we had to complete the questionnaire
through interviews, which was one of the limitations of this
research. Second, it should also be noted that applying the modi-
fication indices to guide CFA analysis increases the probability of
the findings being influenced by chance.
Conclusion
In sum, the results of the present study show that the Persian
scale of uncertainty in illness is a scale that not only has a good
validity and reliability but also its four-dimensional structure is
confirmed. Therefore, it is applicable to assess uncertainty in illness
in Iranian patients with cancer. Use of this scale by nurses and re-
searchers can help to promote nurses’ knowledge and holistic care
and ultimately help to improve patient care. This study will be a
cornerstone for the future studies in the area of uncertainty in
illness in other groups of patients in Iran. Regarding the cognitive
sense of uncertainty in illness, qualitative studies are needed to
know its other possible dimensions in Iranian patients.
Conflict of interest
The authors declare no conflicts of interest.
Acknowledgment
The present study is a research project adopted by Shahid
Beheshti University of Medical Sciences (Tehran e Iran) and a part
of a nursing doctoral thesis. Hereby, we express our appreciation to
Shahid Beheshti Nursing and Midwifery School officials, and also
authorities and staff in wards and Iran Cancer Center of Imam
Khomeini Hospital and Tehran Taleghani Hospital. Finally, we
particularly thank all the participants.
References
Bailey Jr., D.E., Landerman, L., Barroso, J., Bixby, P., Mishel, M.H., Muir, A.J., et al.,
2009. Uncertainty, symptoms, and quality of life in persons with chronic hep-
atitis C. Psychosomatics 50, 138e146.
 M. Sajjadi et al. / European Journal of Oncology Nursing 18 (2014) 52e57
Bailey Jr., D.E., Wallace, M., Latini, D.M., Hegarty, J., Carroll, P.R., Klein, E.A., et al.,
2011. Measuring illness uncertainty in men undergoing active surveillance for
prostate cancer. Applied Nursing Research : ANR 24, 193e199.
Bentler, P.M., 1990. Comparative fit indexes in structural models. Psychological
Bulletin 107, 238e246.
Brashers, D.E., Neidig, J.L., Goldsmith, D.J., 2004. Social support and the manage-
ment of uncertainty for people living with HIV or AIDS. Health Communication
16, 305e331.
Brown, T.A., 2006. Confirmatory Factor Analysis for Applied Research. The Guilford
Press, New York.
Chen, S.C., Yu, W.P., Chu, T.L., Hung, H.C., Tsai, M.C., Liao, C.T., 2010. Prevalence and
correlates of supportive care needs in oral cancer patients with and without
anxiety during the diagnostic period. Cancer Nursing 33, 280e289.
Detprapon, M., Sirapo-ngam, Y., Mishel, M.H., Sitthimongkol, Y., Vorapongsathorn, T.,
2013. Testing of uncertainty in illness theory to predict quality of life among Thais
with head and neck cancer. Pacific Rim International Journal of Nursing Research
13, 1e15.
Flemme, I., Edvardsson, N., Hinic, H., Jinhage, B.M., Dalman, M., Fridlund, B., 2005.
Long-term quality of life and uncertainty in patients living with an implantable
cardioverter defibrillator. Heart & lung : the Journal of Critical Care 34, 386e
392.
Haisfield-Wolfe, M.E., McGuire, D.B., Soeken, K., Geiger-Brown, J., De Forge, B.,
Suntharalingam, M., 2012. Prevalence and correlates of symptoms and un-
certainty in illness among head and neck cancer patients receiving definitive
radiation with or without chemotherapy. Supportive Care in Cancer: Official
Journal of the Multinational Association of Supportive Care in Cancer 20,
1885e1893.
Hallberg, L.R., Erlandsson, S.I., 1991. Validation of a Swedish version of the Mishel
Uncertainty in Illness Scale. Scholarly Inquiry for Nursing Practice 5, 57e65.
Harrow, A., Wells, M., Barbour, R.S., Cable, S., 2008. Ambiguity and uncertainty: the
ongoing concerns of male partners of women treated for breast cancer. Euro-
pean Journal of Oncology Nursing : the Official Journal of European Oncology
Nursing Society 12, 349e356.
Hawthorne, D., Youngblut, J.M., Brooten, D., 2011. Psychometric evaluation of the
Spanish and English versions of the spiritual coping strategies scale. Journal of
Nursing Measurement 19, 46e54.
Helsen, K., Van den Bussche, E., Vlaeyen, J.W.S., Goubert, L., 2013. Confirmatory
factor analysis of the Dutch Intolerance of Uncertainty Scale: comparison of the
full and short version. Journal of Behavior Therapy and Experimental Psychiatry
44, 21e29.
Hillen, M.A., Butow, P.N., Tattersall, M.H.N., Hruby, G., Boyle, F.M., Vardy, J., et al.,
2013. Validation of the English version of the Trust in Oncologist Scale (TiOS).
Patient Education and Counseling 91, 25e28.
Kline, R.B., 2010. Principles and Practice of Structural Equation Modeling, third ed.
The Guilford Press, New York.
Kurita, K., Garon, E.B., Stanton, A.L., Meyerowitz, B.E., 2013. Uncertainty and
psychological adjustment in patients with lung cancer. Psycho-oncology 22,
1396e1401.
Lasker, J.N., Sogolow, E.D., Olenik, J.M., Sass, D.A., Weinrieb, R.M., 2010. Uncertainty
and liver transplantation: women with primary biliary cirrhosis before and
after transplant. Women & Health 50, 359e375.
Lin, L., Acquaye, A.A., Vera-Bolanos, E., Cahill, J.E., Gilbert, M.R., Armstrong, T.S.,
2012. Validation of the Mishel’s uncertainty in illness scale-brain tumor form
(MUIS-BT). Journal of Neuro-Oncology 110, 293e300.
LoBiondo-Wood, G., Haber, J., Kovner, C.T., 2006. Nursing Research: Methods and
Critical Appraisal for Evidence-based Practice, sixth ed. Mosby, St. Louis.
Madar, H., Bar-Tal, Y., 2009. The experience of uncertainty among patients having
peritoneal dialysis. Journal of Advanced Nursing 65, 1664e1669.
57
Mauro, A.M., 2010. Long-term follow-up study of uncertainty and psychosocial
adjustment among implantable cardioverter defibrillator recipients. Interna-
tional Journal of Nursing Studies 47, 1080e1088.
Michaeli Manee, F., 2011. Internal consistency and confirmatory factor analysis of
Wells and Davis Thought Control Questionnaire. Iranian Journal of Psychiatry
and Clinical Psychology 16, 468e478.
Mishel, M.H., 1988. Uncertainty in illness. Imageethe Journal of Nursing Scholarship
20, 225e232.
Mishel, M.H., 1990. Reconceptualization of the uncertainty in illness theory. Image
e J. Nurs. Scholarsh. 22, 256e262.
Mishel, M.H., 1997a. Uncertainty in acute illness. Annual Review of Nursing
Research 15, 57e80.
Mishel, M.H., 1997b. Uncertainty in Illness Scales Manual. M. Mishel at the Uni-
versity of North Carolina-Chapel Hill, School of Nursing, Chapel Hill, NC.
Mishel, M.H., 2013. Theories of uncertainty in illness. In: Smith, M., Liehr, P. (Eds.),
Middle Range Theory for Nursing, third ed. Springer, New York.
Neville, K.L., 2003. Uncertainty in illness: an integrative review. Orthopaedic
Nursing 22, 206e214.
Pai, A.L.H., Mullins, L.L., Drotar, D., Burant, C., Wagner, J., Chaney, J.M., 2007.
Exploratory and confirmatory factor analysis of the child uncertainty in illness
scale among children with chronic illness. Journal of Pediatric Psychology 32,
288e296.
Parker, P.A., Alba, F., Fellman, B., Urbauer, D.L., Li, Y., Karam, J.A., et al., 2013. Illness
uncertainty and quality of life of patients with Small Renal tumors undergoing
Watchful Waiting: a 2-year Prospective Study. European Urology 63, 1122e1127.
Polit, D.F., Beck, C.T., 2013. Essentials of Nursing Research: Appraising Evidence for
Nursing Practice, eighth ed. Lippincott Williams & Wilkins, Philadelphia. USA.
Rasaf, M.R., Ramezani, R., Mehrazma, M., Asadi-Lari, M., 2012. Inequalities in cancer
distribution in tehran; a disaggregated estimation of 2007 incidencea by 22
districts. International Journal of Preventive Medicine 3, 483e492.
Seo, D.-C., Torabi, M.R., Blair, E.H., Ellis, N.T., 2004. A cross-validation of safety climate
scale using confirmatory factor analytic approach. Journal of Safety Research 35,
427e445.
Shaha, M., Cox, C.L., Talman, K., Kelly, D., 2008. Uncertainty in breast, prostate, and
colorectal cancer: implications for supportive care. Journal of Nursing Schol-
arship: An Official Publication of Sigma Theta Tau International Honor Society
of Nursing/Sigma Theta Tau 40, 60e67.
Sherman, A.C., Simonton, S., 2010. Advances in quality of life research among head
and neck cancer patients. Current Oncology Reports 12, 208e215.
Sodowsky, K., 2012. Spousal Caregiver Narratives and Credible Authority: uncer-
tainty in illness of Spousal Caregivers. The Qualitative Report 17, 1e24.
Stewart, J.L., Lynn, M.R., Mishel, M.H., 2010a. Psychometric evaluation of a new
instrument to measure uncertainty in children and adolescents with cancer.
Nursing Research 59, 119e126.
Stewart, J.L., Mishel, M.H., Lynn, M.R., Terhorst, L., 2010b. Test of a conceptual model
of uncertainty in children and adolescents with cancer. Research in Nursing &
Health 33, 179e191.
Vagharseyyedin, S.A., Vanaki, Z., 2011. Validation of the Iranian version of the un-
certainty in illness scale-family form. Journal of Research in Nursing 16, 53e62.
Wild, D., Grove, A., Martin, M., Eremenco, S., McElroy, S., Verjee-Lorenz, A., et al., 2005.
Principles of good Practice for the translation and Cultural adaptation process for
patient-reported outcomes (PRO) measures: report of the ISPOR Task Force for
translation and Cultural adaptation. Value in Health: The Journal of the Inter-
national Society for Pharmacoeconomics and Outcomes Research 8, 94e104.
Woodgate, R.L., Degner, L.F., 2002. “Nothing is carved in stone!”: uncertainty in
children with cancer and their families. European Journal of Oncology Nursing:
The Official Journal of European Oncology Nursing Society 6, 191e202 (Dis-
cussion 203e194).