Abstract There is a critical gap between the resources available to promote health and wellness after cancer and services that address these public health goals. Researchers, policy makers, healthcare providers, and community stakeholders increasingly recognize the benefits of filling this gap with trained peer mentors who can provide health-promotion services to fellow cancer survivors. This commentary addresses a mixed-method study by Pinto and colleagues that investigated the responses and experiences of trained peer mentors who delivered their telephone-based physical activity intervention for breast cancer survivors. Their findings suggested that peer mentors did not experience harms from their role while revealing that peer mentors reported benefits related to helping themselves and helping others. Drawing on our expertise in peer support provision and peer mentoring, we address the significant opportunity offered by training peer mentors to deliver behavioral interventions, draw connections to relevant literatures and theoretical perspectives on potential benefits for peer mentors, and highlight the need for rigorous, theory-based research to determine the circumstances under which peer mentoring benefits mentors and the mechanisms underlying these benefits. INTRODUCTION Given the large and growing population of cancer survivors in the USA [1–3], there are substantial clinical, public health, and societal benefits to be gained by helping survivors adopt lifestyle behaviors that optimize their physical and psychological health, functioning, and quality of life. Physical activity is clearly one such behavior, with substantial evidence for its benefits among those affected by cancer [4–10]. Yet, the resources available to promote health and wellness after cancer are not on track to keep pace with the increasing need. With this in mind, we commend Pinto and colleagues  for their research investigating a way to fill the gap between recognized need and available resources: highly motivated, trained lay volunteers who have been treated for cancer and want to assist others navigating the cancer journey. As the authors note, the strong motivation to volunteer as a peer mentor is suggested by the success of the American Cancer Society’s Reach to Recovery program and similar efforts to harness survivors’ willingness to share their time and learned wisdom. We would add that there also is likely to be an untapped community of cancer survivors who would like to support others’ recovery, despite being limited in their ability to devote substantial time and effort to peer mentoring. Some may be able and willing to take on a less intensive, but still valuable, peer mentoring role. Broad interest in volunteering to be a peer mentor takes on new meaning in light of data showing that peer mentors can benefit from the act of mentoring others. Pinto and colleagues have previously reported evidence from interventional research in which peer mentoring helped cancer survivors increase their moderate-to-vigorous physical activity [12–14]. In addition to reporting benefits of receiving peer mentoring, the investigators now present data to support their mentors’ anecdotal accounts of having benefitted from serving as mentors. Specifically, Pinto and colleagues  report findings from a longitudinal study that used mixed methods to describe their peer mentors’ outcomes. Benefits described by peer mentors in this study—finding meaning in their ability to help others or to “give back”; enhanced sense of worth, purpose, and confidence; building new relationships; enhanced knowledge of the importance of physical activity; and development of valued skills—are consistent with evidence from a broader body of research on volunteerism [15, 16], community or lay health workers , peer mentoring in clinical and research settings [18–20], providing assistance to others in self-help groups [21–23], and other endeavors involving provision of social support [24–27]. In addition to this broad range of related activities, it is notable that this evidence comes from diverse patient and community populations and not just from research with cancer survivors, e.g., Refs. 28 and 29. Providing assistance and support to people who are facing similar challenges appears to fulfill basic human needs. Indeed, these benefits are consistent with multiple theoretical perspectives that apply across groups, including the helper therapy principle , theories of social support processes [24, 31], cognitive adaptation theory , and social determination theory , to offer a few examples. Typical benefits seen in research studying the experiences of peer mentors (e.g., increased knowledge, self-efficacy, benefit finding, meaning-making, and social connectedness) raise the intriguing possibility that providing survivors with the opportunity to serve as peer mentors could be an intervention for improving their health and well-being. The results from the work of Pinto and colleagues suggest that well-trained peer mentors, through the process of helping others, themselves identified increased confidence and improved relationships. Helping activities also stabilized mentors’ own physical activity and quality of life. Thus, peer mentoring has the potential to benefit survivors receiving the mentoring (e.g., by helping them adopt a more active and healthy lifestyle) while establishing a reciprocal benefit among those providing the mentoring—a phenomenon we think of as “reciprocal benefits of helping.” Several researchers have attempted to investigate benefits of providing peer mentoring using experimental research designs. For instance, in a randomized controlled trial, we have found promising evidence for the efficacy of an “expressive helping” intervention that pairs two components: emotionally expressive writing  and peer support writing . In this intervention, cancer survivors completed three brief expressive writing exercises designed to help them translate their treatment experience and its emotional repercussions into language—a process that facilitates cognitive processing, development of a coherent narrative about a severely stressful event, and the ability to communicate about the event with others . These writing exercises prepared them to provide peer support in a fourth brief writing session in which they shared their treatment experiences, advice, and encouragement with fellow survivors . Although we observed improvements in physical and psychological symptoms among participants who completed expressive helping, we agree with Pinto et al. that there are limited outcomes measures available to quantitatively assess the more nuanced benefits and costs related to serving as a peer mentor. Developing appropriate measures would allow this area of research to progress further, and it would also allow researchers to harmonize assessments across randomized controlled trials that use peer mentoring with diverse populations and settings. Not all of our field’s experimental research efforts have succeeded in producing benefit among cancer survivors assigned a peer mentoring role, e.g., Refs. 37 and 38, underscoring the need to develop a more complete theoretical framework to explain and predict benefits of providing peer support. Theory-based research must be paired with rigorous tests of research hypotheses to understand circumstances under which peer mentoring benefits the mentor, or otherwise. Few studies to date have used experimental methods to evaluate use of peer mentoring as an intervention. In fact, most existing studies that provide evidence of peer mentoring benefits use correlational research designs, do not make adequate use of social and behavioral theories, and analyze benefits in small, selected samples of survivors who volunteered to be trained to deliver peer mentoring in a clinical or research setting. In addition to obvious problems related to research on small samples, these mentors are likely to differ in important ways from survivors who might not seek or accept a peer mentoring role. For example, the coaches in the study of Pinto et al. all met or exceeded moderate physical activity recommendations prior to delivering the intervention. Moreover, only 10% of those contacted by Pinto et al. accepted an opportunity to serve as a peer mentor in their physical activity intervention study. Thus, factors related to availability, selectivity, high levels of pre-intervention functioning, and small sample sizes in the existing literature make it difficult to establish a stronger and, indeed, causal link between the provision of peer mentoring and the experience of benefit. These shortcomings in design, methods, and measurement of peer mentor research must be overcome to fully evaluate whether interventions lead to better outcomes among all cancer survivors. The existing evidence could be strengthened by applying gold standard methodologies and newer, more adaptive study designs, by randomizing a sufficiently large sample of survivors to provide peer mentoring or not within an appropriate comparison or control group. There may be also special considerations as to the sequencing, intensity, and staging of such interventions to reach cancer survivors in greatest need. Future work should also consider moderator variables that may identify subgroups most likely to benefit, mechanisms through which benefits occur, and features of an intervention provided by peer mentoring that are critical for ensuring that benefits occur. For instance, in our team’s expressive helping study, cancer survivors only benefitted from writing a peer support narrative if they had first engaged in expressive writing exercises designed to help them cognitively process their treatment experience and translate it to language ; participants who wrote peer support narratives without having first completed expressive writing did not benefit from peer support provision. An additional limitation noted by Pinto et al. was the homogeneity of the coaches in terms of their race, ethnicity, and level of education. Although some prior research involving peer navigators, health educators, or trained community health workers includes samples that are heterogeneous across race, ethnicity, education, and other sociodemographic characteristics, e.g., Ref. 20, other research includes peer mentor samples that are predominantly non-Hispanic White, e.g., Ref. 39. Identifying methods to recruit and train peers from underrepresented racial and ethnic backgrounds will surely expand opportunities in behavioral medicine research and dissemination efforts—allowing for greater generalizability of findings and their potential to influence systems of care. Recent studies have successfully recruited and trained peers as interventionists in the context of cancer survivorship research, e.g., Refs. 40, 41 and 42, suggesting promise for these methods and the deep benefits of collaboration with community-based organizations and other natural helper systems located within the communities where survivors receive their care and where they live, work, and age. As suggested by Pinto and colleagues, identifying ways to successfully enhance cancer survivors’ lifestyle behaviors, such as physical activity, is a significant challenge in cancer control research. The general consistency of the types of benefits found in research on peer mentoring, especially given the heterogeneity of the contexts and populations explored in this research, strongly suggests a phenomenon worth investigating. Peer mentor-delivered interventions hold promise for leveraging a largely untapped resource to provide a cost-effective way to improve health and well-being among both cancer survivors who receive mentoring and those who provide it. Similar models have been proposed in other areas of behavioral research (e.g., to address the obesity epidemic) . As a first step, research such as the work reported by Pinto et al. can generate new hypotheses regarding specific potential benefits of providing peer support, mechanisms of these benefits, and parameters that moderate their effects (e.g., identifying subgroups or circumstances under which benefits are maximally derived or, in contrast, unlikely). As always, this research should be guided by strong theories to direct and inform us, facilitate the translation of research findings, and disseminate those interventions that harness the benefits of peer support provision across a variety of populations. Compliance with Ethical Standards Conflict of Interest: None declared. This manuscript is not being simultaneously submitted elsewhere. No data analyses were conducted for this commentary. Because there are no findings presented in this commentary, we make no statement regarding whether findings were previously published. Because no data analyses were conducted for this commentary, we make no statement regarding whether we have control of primary data for such analyses. Because there were no data presented in this paper, we have no statement about funding sources. References 1. Miller KD , Siegel RL , Lin CC , et al. Cancer treatment and survivorship statistics, 2016 . CA Cancer J Clin . 2016 ; 66 ( 4 ): 271 – 289 . Google Scholar Crossref Search ADS PubMed 2. Bluethmann SM , Mariotto AB , Rowland JH . Anticipating the “Silver Tsunami”: Prevalence trajectories and comorbidity burden among older cancer survivors in the United States . 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Translational Behavioral Medicine – Oxford University Press
Published: Nov 21, 2018
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