چگونه مقایسه اجتماعی در درون یک گروه خودیاری تاثیر سازگاری برای بیماری مزمن دارد؟ مطالعه طولی

Despite the growing popularity of self-help groups for people with chronic illness, there has been surprisingly little research into how these may support adjustment to illness. This study investigated the role that social comparison, occurring within a self-help group, may play in adjustment to chronic illness. A model of adjustment based on control process theory and response shift theory was tested to determine whether social comparisons predicted adjustment after controlling for the catalyst for adjustment (disease severity) and antecedents (demographic and psychological factors). A sample of 301 people with Ménière's disease who were members of the Ménière's Society UK completed questionnaires at baseline and 10-month follow-up assessing adjustment, defined for this study as functional and goal-oriented quality of life. At baseline, they also completed measures of the predictor variables i.e. the antecedents (age, sex, living circumstances, duration of self-help group membership, self-esteem, optimism and perceived control over illness), the catalyst (severity of vertigo, tinnitus, hearing loss and fullness in the ear) and mechanisms of social comparison within the self-help group. The social comparison variables included the extent to which self-help group resources were used, and whether reading about other members’ experiences induced positive or negative feelings. Cross-sectional results showed that positive social comparison was indeed associated with better adjustment after controlling for all the other baseline variables, while negative social comparison was associated with worse adjustment. However, greater levels of social comparison at baseline were associated with a deteriorating quality of life over the 10-month follow-up period. Alternative explanations for these findings are discussed.

Today, upon developing a chronic illness, people are turning more and more to a growing list of self-help groups. In the UK, there are two web site databases giving access to over 2000 illness self-help groups (Garrill & Garrill, 2003; Kenny & Kenny, 2003), and the total number is likely to be much higher because not all self-help groups are listed on these web sites. This growth in popularity assumes a positive role for these groups but, surprisingly, there is little research to either support or contradict this assumption. Self-help groups have been described as patient-led change-oriented organisations (Kurtz, 1997). A number of studies have suggested that support groups may provide valuable social support (Molinari, Nelson, Shekelle, & Crothers, 1994; Spiegel, Bloom, Kraemer, & Gottheil, 1989; Steffen, 1997; Taylor, Falke, Shoptaw, & Lichtman, 1986) including complementary forms of instrumental, emotional and informational support (Bauman, Gervey, & Siegel, 1992; Natterlund & Ahlstrom, 1999). Providing informational support may be also be an important role played by support groups (Bauman et al., 1992; Citron, Solomon, & Draine, 1999). A study of HIV/AIDS and cancer self-help groups (Adamsen, 2002) found that over one-third of their participants reported that group participation assisted with their understanding of their own situation. In addition to social support and information, it has been suggested that social comparison processes may be central to the effects of group participation (Gibbons & Gerrard, 1989; Medvene, 1992). Social comparison theory, originally authored by Festinger (1954), proposes that social comparison occurs between similar people or between people with similar problems, and self-help groups consist of just such people. Social comparison is used in situations of fear and/or uncertainty, as the comparison then provides information by which to evaluate one's situation and identify appropriate responses (Aspinwall, Hill, & Leaf, 2002). It has been suggested that downward comparison, where comparison is made with a person who is doing less well, will initiate positive affect as it increases self-esteem (Wills, 1981). Conversely, upward comparison with a person who is better off may result in hope (Taylor & Lobel, 1989). However, the Identification/Contrast model, proposed by Buunk, Collins, Taylor, VanYperen, and Dakof (1990), has argued for the importance of the interpretation of the comparison in determining the type of affect experienced. Depending on how we interpret the situation, when we see others who are better off than ourselves, we could feel optimistic that we could be like that too, or we could feel pessimistic if we believe we could never be like that person. Conversely, downward comparison could result in feeling lucky that we are not in the situation of the target or anxious because we might be in their situation one day. Applying this model to social comparison within self-help groups, it is clear that there could be positive or negative effects from social comparison as there is typically no control within self-help groups over what type of comparison is made, nor over the interpretation of the comparison. This leads to the question: do social comparison processes influence the success or failure of the self-help group in assisting adjustment? Social comparison may influence adjustment to illness by influencing the evaluation of symptoms and their implications, and by suggesting coping mechanisms (Leventhal, Hudson, & Robitaille, 1997). Although there has been little research into the effects of social comparison in self-help groups, Bauman et al. (1992) report that cancer patients gave ‘being able to compare with other cancer patients’ as a reason for joining a group. However, there is indirect evidence from one study that social comparison processes might negatively influence the outcome of support group membership. Helgeson, Cohen, Schulz, and Yasko (2001) studied the effectiveness of two types of support group on adjustment (as measured by the SF-36) to breast cancer. Participants were randomly allocated to one of four groups and results showed that membership of a group providing only education resulted in better adjustment than membership of the control group, a peer discussion group, or the combination group, where both education and peer discussion occurred. While social comparison was not analysed as a predictor of outcome, members of the peer discussion group reported making more downward negative comparisons than those in the education and control groups (Helgeson et al., 2001). In order to elucidate the processes occurring within self-help groups that may influence adjustment, it is important to clearly define the processes whereby adjustment takes place. In this study, we therefore sought to test a model of the role of social comparison in adjustment (see Fig. 1) based on self-regulation theory, drawing particularly on Carver and Scheier's (1990) control process theory, and Sprangers and Schwartz's (1999) response shift theory. Full-size image (53 K) Fig. 1. This theoretical model shows the hypothesised effects of the variables believed to influence adjustment to illness. Figure options Control process theory is a self-regulation model that proposes that all behaviour is goal directed (Carver & Scheier (1990) and Carver & Scheier (2000)). By means of feedback loops, the ideal and actual rate of progression towards our goals is compared in order to produce affect. Moving faster than expected towards positive goals results in positive affect, while moving slower than expected results in negative affect. Consequently, one of the two ways in which adjustment was measured in this study was based on participants’ perceptions of how quickly they were moving towards or away from their goals. Response shift theory describes self-regulation processes that are relevant to adjustment (Sprangers & Schwartz, 1999). The initial ‘catalyst’, in this case the onset of the illness, causes a disruption to quality of life. ‘Mechanisms’ are then employed in order to cope with the altered situation. The way in which the catalyst is interpreted, i.e. the meaning the illness holds for the individual, and the type of mechanism employed are dependent on the ‘antecedents’, those personal and individual characteristics that influence our perceptions and behaviour. The culmination of these processes is a ‘response shift’ (a cognitive shift in perspective) which results in a change in perceived quality of life. It is this process that is believed to be responsible for adjustment to chronic illness, i.e. a return to a satisfactory quality of life despite the persistence of the illness (Sprangers & Schwartz, 1999). Following this model, as our second indicator of adjustment we examined change in quality of life, assessed by a conventional measure of perceived health and functioning. While many mechanisms may be relevant to adjustment to illness, in this study, social comparison was investigated as a mechanism particularly likely to be facilitated by self-help group membership. Expectations for health and coping provide the reference values against which people evaluate their perceived health and functioning (Carr, Gibson, & Robinson, 2001), and these expectations may be derived from social comparisons with other people with the illness (Aspinwall et al., 2002). To test each component of this model of adjustment, it is necessary to consider the psychological antecedents that the literature suggests can influence both quality of life and social comparison. Self-esteem and perceived control over illness are highlighted as important influences on adjustment in Taylor's (1983) cognitive adaptation theory. Optimism is proposed by Carver and Scheier (1990) as being a factor in the initiation of goal-directed behaviour. In addition, all three constructs are reported as having a potentially important influence on the interpretation of social comparison information (Bennebroek, Buunk, Van der Zee, & Grol, 2002; Bogart & Helgeson, 2000; Tennen, McKee, & Affleck, 2000; Wills, 1981; Ybema & Buunk, 1995). Those with high levels of optimism, self-esteem and control are more likely to interpret social comparison information positively. Consequently, in order to establish whether social comparison is independently related to adjustment, it is important to first control for these variables. In this study, we examined the relationship of each proposed element of this model to adjustment in the context of a self-help group for people with Ménière's disease. Ménière's disease is a disabling, progressive disorder of the inner ear causing severe bouts of vertigo, intermittent tinnitus, fluctuating hearing loss, and a feeling of fullness in the ear (Yardley, Dibb, & Osborne, 2003). All participants in our study were members of the Ménière's Society, a national self-help group with over 5500 members. The members interact mainly through a quarterly magazine which contains medical information as well as a large section of ‘letters to the editor’, where members write about their personal experiences of their illness. It is principally by means of this magazine (aptly named Spin) that the members are able to socially compare. Our hypotheses were that in this sample, (a) social comparison processes occurring within the self-help group would be independently related to adjustment in cross-sectional analyses, after controlling for levels of the catalyst and antecedents. Positive interpretations of social comparison information would be associated with better adjustment, and negative interpretations with worse adjustment; (b) social comparison processes would also predict adjustment over time, defined here as change in functional or goal-related quality of life over a 10-month period.

Our findings have potential relevance to the activities of self-help groups, since they suggest that in some circumstances, the opportunities for social comparison they provide could be unhelpful, and that it may be useful to attempt to promote positive interpretation of social comparison information. For example, disseminating stories of people who moved from poor to better quality of life might help those currently struggling with their illness to nonetheless identify with an upward comparison, while editors’ comments might be used to suggest positive coping strategies when printing accounts of members’ negative experiences. However, our study investigated social comparison processes occurring within a subsample of members of just one self-help group with minimal contact between members, and further research is required to determine to what extent the same processes would be found in groups that operated differently, for people with different types of illness. Studies using an experimental design are also needed in order to establish whether the observed relationship between social comparison and worsening quality of life is actually causal, since an alternative explanation is that high levels of negative social comparison may themselves be the result of a third factor, such as health anxiety, that is also responsible for poor adjustment.