Health Psychology

Brief Psychological Intervention in Patients With Cervical

Cancer: A Randomized Controlled Trial
Di Shao, Wen Gao, and Feng-Lin Cao
Online First Publication, August 11, 2016. http://dx.doi.org/10.1037/hea0000407

CITATION
Shao, D., Gao, W., & Cao, F.-L. (2016, August 11). Brief Psychological Intervention in Patients
With Cervical Cancer: A Randomized Controlled Trial. Health Psychology. Advance online
publication. http://dx.doi.org/10.1037/hea0000407
 Health Psychology © 2016 American Psychological Association
2016, Vol. 35, No. 8, 000 0278-6133/16/$12.00 http://dx.doi.org/10.1037/hea0000407

Brief Psychological Intervention in Patients With Cervical Cancer:

A Randomized Controlled Trial
Di Shao, Wen Gao, and Feng-Lin Cao
Shandong University

Objectives: The diagnosis and treatment of cancer is considered a major life stress that has potential
effects on one’s psychological well-being. This study investigated the possible benefits of a brief
psychological intervention based on gratitude and mindfulness for positive and negative affect in patients
with cervical cancer and explored the potentially mediating role of rumination and reappraisal. Methods:
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A randomized controlled trial was conducted in 3 public hospitals in China between April 2014 and
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December 2014. One-hundred twenty postoperative cervical cancer patients were randomly assigned into
an intervention group or a wait-list control group. Participants completed self-report measures of positive
and negative affect, rumination, and reappraisal before and after the 4-week intervention or waiting
period. The outcome effects of the intervention were analyzed by generalized estimating equations
(GEE). Mediation analyses were performed using a nonparametric bootstrapping procedure. Results:
GEE results indicated significant Time ⫻ Group interaction effects on positive affect (B ⫽ 1.60, ␹2 ⫽
25.90, p ⬍ .001), negative affect (B ⫽ ⫺2.13, ␹2 ⫽ 28.02, p ⬍ .001), rumination (B ⫽ ⫺2.48, ␹2 ⫽ 6.48,
p ⫽ .011), and reappraisal (B ⫽ 3.28, ␹2 ⫽ 41.17, p ⬍ .001) for the intervention. The effect of the
intervention on positive and negative affect was mediated by changes in rumination and reappraisal
respectively. Conclusions: The brief psychological intervention improved positive affect and reappraisal
and reduced negative affect and rumination in women with cervical cancer. Findings support the
beneficial effects for implementing this brief psychological intervention in oncology.

Keywords: cervical cancer, gratitude, mindfulness, negative affect, reappraisal

Supplemental materials: http://dx.doi.org/10.1037/hea0000407.supp

Cervical cancer is the third most commonly diagnosed cancer in
women worldwide, with an estimated 529,800 new cases annually
and more than 275,100 deaths per year (Jemal et al., 2011; Siegel,
Naishadham, & Jemal, 2012). The diagnosis and treatment of
cancer is considered a major life stress that has a potential impact
on patients’ psychological well-being. Furthermore, the integrated
treatments of organs that serve reproductive and hormonal func-
tions may have profound implications on female fertility, sexual
function, self-identity, and so on (Le Borgne et al., 2013; Pfaen-
dler, Wenzel, Mechanic, & Penner, 2015). Therefore, cervical
cancer patients have been reported to show worse scores in terms
of emotional distress than the general population or patients bear-
ing other gynecological tumors (Ashing-Giwa et al., 2009; Park et
Di Shao, Wen Gao, and Feng-Lin Cao, School of Nursing, Shandong
University.
Di Shao and Wen Gao contributed equally to this paper. The authors
thank all the participants for their time and efforts. This study was finan-
cially supported by Natural Science Foundation of Shandong Province
(Grant: ZR2013HM087) and Independent Innovation Foundation of Shan-
dong University (Grant: IFW12113). The funders had no role in study
design, data collection and analysis, decision to publish, or preparation of
the manuscript.
Correspondence concerning this article should be addressed to Feng-Lin
Cao, No.44 Wenhua Xi Road, Jinan, Shandong 250012, P.R. China.
E-mail: caofenglin2008@126.com
1
al., 2007). Clearly, psychological interventions that are effective at
improving the emotional state of cervical cancer patients are of
great importance.
Recently, a gratitude diary intervention, a technique involving
thinking about and writing down three grateful things that hap-
pened each day, has been increasingly used to improve psycho-
logical well-being (Seligman, Steen, Park, & Peterson, 2005).
There were benefits of a gratitude diary intervention administered
over a 2-week period on positive affect (PA) in a sample of 166
undergraduate participants (Emmons & McCullough, 2003). In
another study by Emmons and McCullough (2003), participants
who were randomly assigned to a gratitude condition showed
significantly more PA after 3 weeks of intervention. Research on
gratitude diary intervention in healthy populations (especially stu-
dents) has demonstrated efficacy in improving well-being. How-
ever, the effectiveness of the gratitude diary intervention in clinical
populations, especially in cancer patients, is relatively unexplored
(Wood, Froh, & Geraghty, 2010).
In addition, another psychological intervention, mindfulness-
based therapy, which refers to moment-to-moment, open-minded,
and nonjudgmental awareness of internal and external experience,
has been broadly used to reduce psychological symptoms in a wide
variety of populations (Kabat-Zinn, 1994; Shennan, Payne, &
Fenlon, 2011). Among patients with breast cancer, mindfulness-
based interventions have been associated with improved mental
health, less fatigue, and an enhanced quality of life (Matchim,
Armer, & Stewart, 2011; Zainal, Booth, & Huppert, 2013).
 2 SHAO, GAO, AND CAO
Mindfulness-based therapy is typically conducted for 8 weeks, in
weekly 150-min sessions, a 6-hr retreat, and daily home practice
that lasts 45 min in duration (Shennan et al., 2011). Therefore,
traditional mindfulness-based therapy tends to involve a consider-
able time commitment that might limit its usability for individuals
with little available free time. A recent review of the mindfulness-
based interventions literature in oncology has highlighted the need
for more randomized controlled trials; further information regard-
ing the efficacy of brief, at-home practice; and the need to explore
the underlying mechanisms (Ledesma & Kumano, 2009).
Given the extensive evidence base for the efficacy of gratitude
diaries and mindfulness-based interventions, researchers have re-
cently started to explore the potential psychological mechanisms
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underlying their beneficial effects (Gu, Strauss, Bond, & Ca-
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vanagh, 2015; Hölzel et al., 2011; Shapiro, Carlson, Astin, &
Freedman, 2006; Wood et al., 2010). The “broaden-and-build”
theory claims that positive emotions broaden mindsets and build
continued personal resources (Fredrickson, 2001). According to
this theory, gratitude broadens the scope of cognition, enables
flexible thinking, and facilitates coping with stress (Folkman &
Moskowitz, 2000; Fredrickson, 2004). In addition, several re-
searchers have developed theoretical models of mindfulness inter-
ventions that include a range of potential mechanisms. For in-
stance, Hölzel et al. (2011) reviewed neuroscientific findings and
experimental data and examined four potential mechanisms show-
ing how mindfulness-based interventions work: emotional regula-
tion, body awareness, attention regulation, and one’s perspective
change. In addition, Baer (2003) identified self-management (in-
creased adaptive coping skills), cognitive change, and acceptance
as key mechanisms. Taken together, based on the theoretical
underpinnings of gratitude and mindfulness-based interventions,
this study focused on two possible cognitive emotion regulation
mechanisms: the decrease of rumination and the improvement of
reappraisal.
Rumination is defined as thinking repetitively and passively
about one’s symptoms of distress and the possible causes and
consequences of these symptoms. It has been suggested to be a
maladaptive emotional regulation strategy that is usually associ-
ated with higher levels of distress (Nolen-Hoeksema, 1991). Some
cross-sectional and quasi-experimental studies have revealed ru-
mination as one of the ways that emotion is regulated during
mindfulness-based interventions (Desrosiers, Vine, Klemanski, &
Nolen-Hoeksema, 2013; Deyo, Wilson, Ong, & Koopman, 2009).
However, these preliminary studies preclude causal interpretation
because of several methodological flaws (e.g., cross-sectional de-
sign, lack of randomization, and no control-group; Heeren &
Philippot, 2011; Labelle, Campbell, & Carlson, 2010).
Alternatively, reappraisal, an adaptive emotional regulation
strategy, refers to reconstructing the situation in a way that de-
creases its emotional impact (Gross, 2002). Wood et al. (2010)
found that grateful people use coping strategies characterized by
reinterpreting the situation as positive and trying to find the po-
tential for growth, and that reinterpretation mediated the relation-
ship between gratitude and stress. A self-report study revealed that
mindfulness training led to increases in positive reappraisal and
that these mediated an improvement in stress levels; however,
these data preclude causal inference due to the lack of a control
group (Garland, Gaylord, & Fredrickson, 2011). In conclusion,
some theoretical frameworks and empirical studies propose rumi-
nation and reappraisal as mechanisms underlying the gratitude
diary and mindfulness-based interventions; however, no study to
date has directly examined the mediating role of these two vari-
ables in randomized controlled trials (Gu et al., 2015).
To design an intervention that is a convenient tool for self-help,
and is not overly time-consuming or disruptive to cancer patients’
daily routines, we conceived of a brief psychological intervention
that integrated the gratitude diary with the mindfulness-based
intervention. This study investigated the possible benefits of this
brief psychological intervention on affect in cervical cancer pa-
tients and tested the extent that the intervention effects might be
attributable to changes in rumination and reappraisal induced by
the training. We hypothesized that over a 4-week period, patients
assigned to the intervention group would report more PA and
reappraisal, and less negative affect (NA) and rumination com-
pared with patients in the control group. We also expected that the
change in rumination and reappraisal would statistically mediate
the beneficial effects of the intervention on PA and NA.
Methods
Design
A randomized controlled trial was conducted in three public
hospitals in China between April 1, 2014 and December 31, 2014.
Women fulfilling inclusion criteria were identified by a consecu-
tive manual search of medical records of patients undergoing
surgical procedures in these three hospitals and were subsequently
invited to participate. Those who agreed provided informed con-
sent and completed baseline questionnaires the day before dis-
charge (approximately 1 week after their surgical procedure).
Participants were then randomly assigned to one of two groups: an
intervention or a wait-list control group. After a 4-week interven-
tion, participants in both groups were asked again to complete the
questionnaire set. Thereafter, the wait-list control group also re-
ceived the brief psychological intervention.
Participants
The inclusion criteria were (a) newly diagnosed with Stage 0, I,
II, or III cervical cancer; (b) aged 18 years and older; (c) completed
surgical treatments; and (d) ability to read, write, and speak Chi-
nese. Exclusion criteria were (a) concurrent diagnosis of other
tumor types, severe somatic diseases, or psychiatric disorders that
would limit participation in this study; (b) a history of receiving
chemotherapy or radiotherapy; (c) past participation in other types
of psychosocial interventions within 6 months prior to enrollment;
and (d) did not consent to participate. One-hundred ninety-nine
eligible participants were invited, and 120 consented to participate
and completed the baseline assessment.
Randomization. Randomization was determined using SPSS,
version 21.0 for Windows (SPSS Inc., Chicago, IL), which gen-
erated a list of random numbers representing the participants and
allocating them to one of the two groups. Randomization was
conducted by a separate researcher. After randomization, there was
no blinding to group assignment, except for assessment of the
outcomes, which was performed by a research assistant.
Wait-list controls: Usual care. Participants in the wait-list
control group received usual care that included health education
 PSYCHOLOGICAL INTERVENTION IN CANCER
and instructions for follow-up care and rehabilitation. No specific
psychosocial intervention was offered as part of the usual care.
Interventions: Usual care plus the brief psychological
intervention. Participants in the intervention group received
usual care plus a brief psychological intervention. The brief psy-
chological intervention included a gratitude diary intervention and
a mindfulness-based intervention. Participants were asked to write
down three things that they felt grateful for every day and provide
a causal explanation for each thing. They were then required to
listen to a 14-min compact disk, follow the verbal guidance, and
direct their attention to their breath and body sensation in a
nonjudgmental way. This brief intervention took approximately 30
min to complete each day. Participants were required to practice
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the interventions every evening for four consecutive weeks.
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Before the start of the intervention, the instructor scheduled a
preintervention personal interview with each participant to intro-
duce this brief intervention, explain training recommendations,
and answer any questions. Patients were asked to attempt this
intervention the night before discharge and provide feedback to the
instructor so that they could practice correctly. Each participant
was provided with a manual containing instruction and guidance of
this intervention and was asked to read it carefully to gain a better
understanding of our intervention.
Adherence was assessed through practice record sheets. Partic-
ipants were asked to write in the gratitude diary and record their
mindfulness practice on the record sheets. Participants were re-
quired to keep the gratitude diary and practice mindfulness training
every evening during the intervention period. If participants com-
pleted both of the intervention elements in one day, they were
considered adherent. If participants completed only one of the
intervention elements (e.g., recorded mindfulness practice, but did
not write in the gratitude diary), they were considered nonadher-
ent.
Sample size. Informed by previous studies (Emmons & Mc-
Cullough, 2003; Grossman, Niemann, Schmidt, & Walach, 2004),
sample sizes of 60 per group were needed to achieve 80% power
to detect a difference of 0.485 between groups, assuming 20%
attrition (␣ ⫽ .05; calculated using PASS 11).
Measures
Demographics. Demographic and clinical characteristics, in-
cluding age, educational level, family status, employment, stage of
disease, and surgical method were assessed at the time of study
enrollment.
Positive and Negative Affect Schedule. The Positive and
Negative Affect Schedule (PANAS) consists of two, 10-item mood
scales designed to provide independent measures of PA and NA
(Watson, Clark, & Tellegen, 1988). The PA scale reflects the level
of pleasant engagement, the extent that a person feels interested,
attentive, concentrating, strong, inspired, proud, enthusiastic, ex-
cited, active, and determined. The NA scale reflects a general
dimension of negative feelings and subjective distress including
scared, afraid, upset, distressed, jittery, nervous, ashamed, guilty,
irritable, and hostile. Participants were asked to respond on a
5-point Likert scale from 1 (very slightly or not at all) to 5
(extremely). Scores for each scale ranged from 10 to 50, with
higher scores indicating higher affect levels. The PANAS has
displayed excellent psychometric properties (reliability, conver-
3
gent and divergent validity) and it has been translated into several
languages including Chinese (Huang, Yang, & Ji, 2003; Terrac-
ciano, McCrae, & Costa, 2003). The internal consistency for the
PA and NA scale in the present study was strong (Cronbach’s
alpha ⫽ .841 and 0.890, respectively).
Ruminative Responses Scale. The Ruminative Responses
Scale (RRS) developed by Nolen-Hoeksema was used to measure
rumination (e.g., “when I feel down, sad, or depressed, I think
about how alone I feel.”; Nolen-Hoeksema, 1991). Twenty-two
items were rated on Likert-type scales ranging from 1 (almost
never) to 4 (almost always), with higher scores indicating severe
rumination. The RRS has displayed strong reliability and validity
in several studies (Han & Yang, 2009; Nolen-Hoeksema & Mor-
row, 1991), as well as in this study (Cronbach’s alpha ⫽ .897).
Emotion Regulation Questionnaire. Reappraisal was as-
sessed using the cognitive reappraisal subscale of the Emotion
Regulation Questionnaire (ERQ; Gross & John, 2003), which
comprises six items that assess the ability to positively reconstruct
distressing emotional experiences (e.g., “when I want to feel less
negative emotion (such as sadness or anger), I change what I am
thinking about”). Participants responded to each question using a
7-point Likert scale ranging from 1 (strongly disagree) to 7
(strongly agree). Higher scores indicated more reappraisal use.
The Chinese version of the ERQ has demonstrated adequate reli-
ability and validity (Wang, Liu, Li, & Du, 2007). The internal
consistency of the reappraisal subscale in our study was strong
(Cronbach’s alpha ⫽ .757).
Ethical Considerations
The study followed the ethical principles of clinical research and
its protocol was approved by the Research Ethics Committee of the
university sponsoring the research. All patients provided informed
consent and patients were permitted to discontinue participation
without facing any negative consequences.
Statistical Analysis
Means and standard deviations were calculated for continuous
characteristics, and counts and proportions were used for categor-
ical ones. The results of a Kolmogorov–Smirnov test revealed that
none of the continuous variables showed significant deviations
from a normal distribution. Differences in demographics and out-
come variables between groups at baseline were analyzed by an
independent t test or a chi-square test. To compare changes in the
two groups over time, generalized estimated equations (GEE)
models with an unstructured correlation matrix were fitted. All
analyses were controlled for demographics and medical character-
istics.
The nonparametric bootstrapping procedure recommended by
Preacher and Hayes (2004) was used to examine indirect ef-
fects. The traditional series of regression analyses recom-
mended by Baron and Kenny (1986) was also used to analyze
mediation effects. For both mediators and outcomes, we used
residual change scores (e.g., the difference between the ob-
served score at postintervention and the predicted score at
postintervention, when the baseline measure is used to predict
the postintervention score; MacKinnon, 2008). The intention-
to-treat principle was used to analyze participants, and missing
 4 SHAO, GAO, AND CAO
data were managed using the last-observation-carried-forward
method. Statistical analyses were performed with SPSS, version
21.0 for Windows.
Results
Participant Enrollment and Dropouts
We approached 199 eligible patients; 120 patients consented to
participate, completed baseline measures, and were included in the
intention-to-treat analysis. Ninety-five patients (79.2%) completed
the study: 49 of them (51.6%) were from the intervention group
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and 46 (48.4%) were from the wait-list group. There were no
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significant differences between dropouts and the rest of the sample
on demographic variables and outcome measures with the excep-
tion of age (p ⫽ .002), education (p ⫽ .001), stage of disease (p ⫽
.003), and rumination scores (p ⬍ .001). Moreover, the dropouts
were more likely to be younger, currently in Stage II of the disease,
Figure 1. CONSORT flow diagram.
less educated, and have less rumination scores at baseline com-
pared with those who completed the study.
The mean number of days of home practice for the 49 patients
who provided complete follow-up data in the intervention group
was 25.20 days (SD ⫽ 1.68 days, range ⫽ 22–28 days) over 4
weeks. Specifically, participants wrote an average of 2.7 grateful
things per day (SD ⫽ 0.18) and reported a mean of 12.6 min/day
(SD ⫽ 0.84) of mindfulness practice over the intervention period.
For a diagram of participant flow through the study, please see
Figure 1.
Baseline Characteristics
Table 1 shows the baseline characteristics of the study sample.
Groups were balanced on demographics and medical characteris-
tics at baseline (p ⬎ .1 for all tests). Importantly, there were no
significant differences between groups on PA (p ⫽ .055), NA (p ⫽
.210), rumination (p ⫽ .382), or reappraisal (p ⫽ .870).
 PSYCHOLOGICAL INTERVENTION IN CANCER 5

Table 1
Demographics and Medical Characteristics of the Intervention Group and Wait-List Control
Group at Baseline (N ⫽ 120)

Characteristics Intervention Control (n ⫽ 60) t/␹2 p

Age, M (SD) 46.58 (9.94) 44.50 (9.09) 1.198 .233

Education, n (%) .178 .833
High school or below 44 (73.4) 46 (76.7)
Above high school 16 (26.6) 14 (23.3)
Family status, n (%) ⬍.001 1.000
Living alone 6 6
Living with family members 54 54
Employment, n (%) 2.476 .177
Employed 44 (73.3) 51 (85.0)
Unemployed or retired 16 (26.7) 9 (15.0)
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Stage of disease, n (%) .192 .909

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0 14 (23.3) 14 (23.3)
I 31 (51.7) 29 (48.3)
II 15 (25.0) 17 (28.3)
Type of surgery, n (%) .976 .614
Cervical conization 12 9
Cervical resection 35 34
Radical hysterectomy 13 17

Effects on Outcome Variables We also included the number of days of home practice in GEE
models to examine a potential dose-dependent relationship be-
Mean scores of outcome variables for each time are presented in tween the number of days of practice and psychological outcomes.
Table 2. The effect of the brief psychological intervention on Increased days of home practice predicted significant improve-
outcome variables was analyzed using GEE models. The results ments in rumination; however, the improvements in PA, NA, and
showed significant interaction of Time ⫻ Group for PA (p ⬍ .001) reappraisal were independent of the home practice amount (see
and NA (p ⬍ .001). This could be interpreted as a significant Table 3).
increase in PA and a sharper decrease in NA for the intervention In addition, we performed per-protocol analyses (PPA) using the
group as compared with controls. In addition, a significant inter- data for those who successfully completed both baseline and
action of Time ⫻ Group emerged for rumination (p ⫽ .011) and follow-up assessments (n ⫽ 95). The subsequent PPA also showed
reappraisal (p ⬍ .001) was found, revealing that the intervention
group experienced a moderate reduction in rumination and a larger
increase in reappraisal (see Table 3). Table 3
Results of Generalized Estimating Equations Analyses Based on
the Intention-to-Treat Sample (N ⫽ 120)
Table 2
Outcomes B (95% CI) SE Wald ␹2 p
Means and Standard Deviations on Outcome Variables for the
Intervention Group and Wait-List Control Group at Baseline Positive affect
and Follow-Up (N ⫽ 120) Time ⫺1.47 (⫺2.05, ⫺.89) .29 24.75 ⬍.001
Group ⫺1.65 (⫺4.18, .89) 1.29 1.62 .203
Baseline, Follow-up, Effect Time ⫻ Group 1.60 (.98, 2.22) .31 25.90 ⬍.001
Variable M (SD) M (SD) size (d) Days for practice .06 (⫺.04, .15) .05 1.23 .267
Negative affect
Positive affect Time 1.92 (1.42, 2.42) 2.55 56.38 ⬍.001
Intervention group 24.78 (2.31) 26.25 (3.18) .529 Group 2.52 (⫺.28, 5.33) 1.43 3.12 .078
Control group 23.50 (3.13) 23.37 (3.15) Time ⫻ Group ⫺2.13 (⫺2.92, ⫺1.34) .40 28.02 ⬍.001
Negative affect Days for practice .07 (⫺.04, .17) .05 1.58 .209
Intervention group 22.67 (3.18) 20.75 (2.47) .674 Rumination
Control group 21.77 (4.53) 21.98 (4.70) Time 3.72 (2.38, 5.06) .68 29.56 ⬍.001
Rumination Group 7.15 (3.96, 10.35) 1.63 19.23 ⬍.001
Intervention group 37.77 (8.27) 34.05 (4.88) .548 Time ⫻ Group ⫺2.48 (⫺4.40, ⫺.57) .98 6.48 .011
Control group 39.02 (7.31) 37.78 (8.64) Days for practice .18 (.07, .29) .05 10.71 .001
Reappraisal Reappraisal
Intervention group 23.22 (4.09) 26.10 (2.81) .820 Time ⫺2.88 (⫺3.62, ⫺2.15) .38 59.13 ⬍.001
Control group 23.08 (4.76) 22.68 (4.42) Group ⫺5.00 (⫺7.44, ⫺2.56) 1.25 16.09 ⬍.001
Time ⫻ Group 3.28 (2.28, 4.29) .51 41.17 ⬍.001
Note. Effect size d was calculated based on the difference between the Days of practice ⫺.09 (⫺.19, .01) .52 2.89 .089
group means on baseline and follow-up, and dividing it by the pooled
standard deviation at baseline and follow-up; d ⫽ .2 defined as small, d ⫽ Note. CI ⫽ confidence intervals. All analyses were controlled for demo-
.5 defined as medium, and d ⫽ .8 defined as large. graphics and medical characteristics.
 6 SHAO, GAO, AND CAO

a significant Time ⫻ Group interaction for PA and NA and for
rumination and reappraisal (all ps ⬍.001). Increased days of home
practice predicted significant improvements in NA (p ⫽ .019),
rumination (p ⬍ .001), and reappraisal (p ⫽ .002); however, the
improvements in PA were independent of the home practice
amount (p ⫽ .481). The detailed PPA results are available in an
online Supplemental Appendix.
Tests of Mediating Role of Rumination and
Reappraisal
The final analyses that tested for the mediation effect of rumi-
nation and reappraisal were conducted using nonparametric boot-
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Anselmo-Matthews, 2012). Our results were also consistent with
previous studies that demonstrated a positive effect of
mindfulness-based interventions in mental health, perceived stress,
depression, anxiety, and improved quality of life among patients
with cancer, especially breast cancer (Matchim et al., 2011; Shen-
nan et al., 2011; Zainal et al., 2013). The effect size was moderate
for positive and negative affect in our study, which was consistent
with previous literature (Emmons & McCullough, 2003). A meta-
analysis determined that the overall effect of mindfulness-based
intervention on mental health was 0.54 for randomized studies
(Grossman et al., 2004). The results obtained are encouraging, and
will be very useful for implementing this brief psychological
intervention in oncology.

strap procedures. Rumination significantly mediated the effects of In addition, women who received the brief psychological inter-
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the brief psychological intervention on PA (95% confidence inter-
val [CI] lower and upper ⫽ ⫺0.023, ⫺0.003; Kappa-squared ⫽
0.07) and a Sobel test revealed statistical significance (Z ⫽ ⫺1.99,
p ⫽ .047). Reappraisal significantly mediated the direct effects of
brief psychological intervention on NA (95% CI lower and up-
per ⫽ ⫺2.455, ⫺1.144; Kappa-squared ⫽ 0.37) and a Sobel test
revealed statistical significance (Z ⫽ ⫺5.58, p ⬍ .001). The results
of the nonparametric bootstrap procedures are presented in Table
4. Path diagrams representing the statistically significant mediated
effects are depicted in Figure 2.
Discussion
This study examined the hypothesized benefit of a brief psy-
chological intervention for PA and NA in women with cervical
cancer and tested the potential mediating roles of changes in
rumination and reappraisal. In general, the results confirmed our
hypotheses.
As predicted, cervical cancer patients who participated in the
brief psychological intervention reported more PA and less NA
following the intervention when compared with the wait-list con-
trol group. The improvement in affective experience after the
intervention was consistent with previous experimental studies and
literature supporting the beneficial effect of a gratitude diary
intervention and mindfulness-based interventions (Mongrain &
vention demonstrated less rumination and greater reappraisal fol-
lowing the intervention when compared with controls. Significant
decrease in rumination reinforced and extended the results found
in other studies that evaluated rumination after mindfulness-based
interventions (Heeren et al., 2011; Labelle et al., 2010). The
improvement in reappraisal was an important finding that added to
the evidence base not only for mindfulness-based interventions,
but also to the effectiveness of the gratitude diary intervention.
Collectively, through the brief psychological intervention, patients
tended to use more adaptive emotion regulation strategies charac-
terized by positive reinterpretation of potentially stressful situa-
tions. They are taught to be present in reality rather than ruminat-
ing over the past (Morgan, 2003; Wood et al., 2010).
It is noteworthy that the impact of the brief psychological
intervention on NA was partially mediated by an increase in
reappraisal, pointing to a possible mechanism underlying the brief
psychological intervention for this specific outcome. The Kappa-
squared mediation effect size, which could be interpreted as the
proportion of the maximum possible indirect effect that could have
occurred, was 37% (Preacher & Kelley, 2011). This was the first
randomized clinical trial to examine reappraisal as a potential
mediator in the gratitude diary and mindfulness-based interven-
tions. Consistent with previous theoretical reviews (Hölzel et al.,
2011; Wood et al., 2010) and critical preliminary findings (Gar-

Table 4
Results of Mediation Analyses Using Non-Parametric Bootstrap Procedures

Bootstrap results for indirect effect

Outcome Mediator Path Effect (SE) LLCI ULCI
ⴱ
Positive affect Rumination a⫻b ⫺.01 (.01) ⫺.023 ⫺.003
R-squared ⫺.03 (.02)ⴱ ⫺.076 ⫺.006
Kappa-squared .07 (.03)ⴱ .022 .153
Reappraisal a⫻b ⫺.01 (.01) ⫺.037 .013
R-squared ⫺.01 (.03) ⫺.078 .037
Kappa-squared .06 (.05) .002 .182
Negative affect Rumination a⫻b ⫺.31 (.21) ⫺.801 .007
R-squared .06 (.04) .007 .149
Kappa-squared .07 (.04) .006 .173
Reappraisal a⫻b ⫺1.77 (.33)ⴱ ⫺2.455 ⫺1.144
R-squared .18 (.06)ⴱ .070 .302
Kappa-squared .37 (.06)ⴱ .253 .478
Note. Number of bootstrap re-samples ⫽ 5000; a ⫻ b ⫽ indirect effect; LLCI ⫽ lower level of confidence
intervals; ULCI ⫽ upper level of confidence intervals.
ⴱ
Significant point estimate as determined by absence of zero within the 95% confidence intervals.
 PSYCHOLOGICAL INTERVENTION IN CANCER 7
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This document is copyrighted by the American Psychological Association or one of its allied publishers.

Figure 2. Path diagrams representing statistically significant mediated effects. Standardized beta estimates are
shown. Path a is the estimate of the effect of group on mediators. Path b is the estimate of the effect of mediators
on dependent variables adjusted for group. Path c’ is the estimate of the direct effect of the group on dependent
variables adjusted for mediators. Path c is the estimate of total effect of the group on dependent variables. ⴱ p ⬍
.05. ⴱⴱp ⬍ .01. ⴱⴱⴱ p ⬍ .001.

land et al., 2011), these results demonstrated that the mechanisms
involved in the gratitude diary and mindfulness-based interven-
tions act promoted reconstruction of the stressful situation as
positive and beneficial (reappraisal), thereby decreasing NA.
In addition, the impact of the brief psychological intervention on
PA was partially mediated by a decrease in rumination. This
finding was consistent with previous research suggesting that
rumination is one of the ways that emotion gets regulated during
mindfulness-based interventions (Desrosiers et al., 2013; Deyo et
al., 2009; Heeren et al., 2011; Labelle et al., 2010). In the descrip-
tion of mindfulness-based therapy, Segal and colleagues stressed
the importance of disengaging attention from maladaptive rumi-
native thoughts (Morgan, 2003). In fact, during this brief psycho-
logical intervention, attentional focus is redirected from automat-
ically ruminative thoughts to a concrete focus (e.g., breathing, the
body, or grateful things in life), thereby regulating the emotion.
The Kappa-squared mediation effect size was 7%, indicating that
future studies examining other potential mediators are warranted.
Previous research on mediators of mindfulness-based interventions
has typically targeted improvements in mindfulness; however, a
range of other potential mediators, including but not limited to
emotional regulation, should also be proposed.
This study is a step forward in exploring new possibilities for
psychological interventions in oncology. The universal need to
decrease psychological suffering is highly prevalent considering
the burden of emotional distress in oncology. Because offering
integral care to hospitalized oncology patients is fundamental, it
becomes necessary to have strategies oriented toward promoting
well-being after discharge, especially when patients have to cope
with subsequent radiotherapy or chemotherapy (Andrykowski, Ly-
kins, & Floyd, 2008; Shennan et al., 2011). This research contrib-
utes to discovering effective and widely accessible means to meet
such goals. This brief intervention is differentiated from previous
psychosocial interventions in several ways. First, this intervention
 8 SHAO, GAO, AND CAO
is not complicated, nor does it comprise many steps. Second, it
does not require extensive guidance or education from psycholog-
ical therapists to administer. Therefore, this intervention is a con-
venient, self-help tool for cervical cancer patients to use at home.
Moreover, it has the potential to increase their access to psycho-
logical services and improve their mental health.
A number of limitations should be noted concerning this study.
First, the data were based on self-reports of adherence. There is a
possibility that the intervention group participants were biased in
their reporting of adherence. Second, our results were restricted to
immediate postintervention effects. A long-term analysis of the
effectiveness of the brief psychological intervention is necessary.
Third, the sample included only cervical cancer patients who had
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
completed surgical treatment; therefore, these findings may not be
This document is copyrighted by the American Psychological Association or one of its allied publishers.
generalizable to patients who underwent other treatments or sur-
vivors of other types of cancer. Of note, given that women who
were younger, less educated, currently in Stage II of the disease,
and who had lower rumination scores were more likely to drop out
of the study, it is unclear whether the intervention would yield
similar benefits among this subgroup of patients. Future research is
warranted that identifies the specific barriers to participation or
reasons for dropout in this subgroup.
Despite these limitations, this study demonstrated the effective-
ness of a brief psychological intervention involving a gratitude
diary and a mindfulness exercises in cervical cancer patients. The
intervention targets showed an improvement in their emotional
states, an enhancement of adaptive emotion regulation strategies
(reappraisal), and the alleviation of maladaptive emotion regula-
tion strategies (rumination) in a brief, simple, and convenient way
at home. Future research might directly test the effect of this brief
psychological intervention on other psychological outcomes (per-
ceived stress, depression, anxiety, sleep quality, etc.). In addition,
future research should provide insight on the threshold dose (i.e.,
the minimum, yet effective) as well as the dose-dependent rela-
tionship between the number of days of home practice and psy-
chological outcomes. Future research might also include other
potential mediators, and look at long-term efficacy of this inter-
vention in larger randomized controlled trials.
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Received September 4, 2015
Revision received May 22, 2016
Accepted June 5, 2016 䡲