The science of peer support as applied to behavioral medicine and the care of individuals surviving with cancer: a commentary on “Peer mentors delivering a physical activity intervention for cancer survivors: effects among mentors by Pinto et al.”

The science of peer support as applied to behavioral medicine and the care of individuals... 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 [11] 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 [11] 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 [17], 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 [30], theories of social support processes [24, 31], cognitive adaptation theory [32], and social determination theory [33], 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 [34] and peer support writing [35]. 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 [36]. 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 [35]. 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 [35]; 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) [43]. 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 . Cancer Epidemiol Biomarkers Prev . 2016 ; 25 ( 7 ): 1029 – 1036 . Google Scholar Crossref Search ADS PubMed 3. de Moor JS , Mariotto AB , Parry C , et al. Cancer survivors in the United States: Prevalence across the survivorship trajectory and implications for care . Cancer Epidemiol Biomarkers Prev . 2013 ; 22 ( 4 ): 561 – 570 . Google Scholar Crossref Search ADS PubMed 4. Buffart LM , Kalter J , Sweegers MG , et al. Effects and moderators of exercise on quality of life and physical function in patients with cancer: An individual patient data meta-analysis of 34 RCTs . Cancer Treat Rev . 2017 ; 52 : 91 – 104 . Google Scholar Crossref Search ADS PubMed 5. Rogers LQ , Courneya KS , Anton PM , et al. Effects of a multicomponent physical activity behavior change intervention on fatigue, anxiety, and depressive symptomatology in breast cancer survivors: Randomized trial . Psychooncology . 2017 ; 26 ( 11 ): 1901 – 1906 . Google Scholar Crossref Search ADS PubMed 6. Rogers LQ , Courneya KS , Carter SJ , et al. Effects of a multicomponent physical activity behavior change intervention on breast cancer survivor health status outcomes in a randomized controlled trial . Breast Cancer Res Treat . 2016 ; 159 ( 2 ): 283 – 291 . Google Scholar Crossref Search ADS PubMed 7. Schmitz KH , Ahmed RL , Troxel AB , et al. Weight lifting for women at risk for breast cancer-related lymphedema: A randomized trial . JAMA . 2010 ; 304 ( 24 ): 2699 – 2705 . Google Scholar Crossref Search ADS PubMed 8. Rock CL , Flatt SW , Byers TE , et al. Results of the Exercise and Nutrition to Enhance Recovery and Good Health for You (ENERGY) trial: A behavioral weight loss intervention in overweight or obese breast cancer survivors . J Clin Oncol . 2015 ; 33 ( 28 ): 3169 – 3176 . Google Scholar Crossref Search ADS PubMed 9. Demark-Wahnefried W , Colditz GA , Rock CL , et al. ; ENERGY Trial Group . Quality of life outcomes from the Exercise and Nutrition Enhance Recovery and Good Health for You (ENERGY)-randomized weight loss trial among breast cancer survivors . Breast Cancer Res Treat . 2015 ; 154 ( 2 ): 329 – 337 . Google Scholar Crossref Search ADS PubMed 10. Rogers LQ , Courneya KS , Oster RA , et al. Physical activity and sleep quality in breast cancer survivors: A randomized trial . Med Sci Sports Exerc . 2017 ; 49 ( 10 ): 2009 – 2015 . Google Scholar Crossref Search ADS PubMed 11. Pinto BM , Dunsiger S , Stein K , Kamson C . Peer mentors delivering a physical activity intervention for cancer survivors: Effects among mentors . Transl Behav Med . 2017 ; 7 ( 4 ): 680 – 689 . Google Scholar Crossref Search ADS PubMed 12. Pinto BM , Frierson GM , Rabin C , Trunzo JJ , Marcus BH . Home-based physical activity intervention for breast cancer patients . J Clin Oncol . 2005 ; 23 ( 15 ): 3577 – 3587 . Google Scholar Crossref Search ADS PubMed 13. Pinto BM , Stein K , Dunsiger S . Peers promoting physical activity among breast cancer survivors: A randomized controlled trial . Health Psychol . 2015 ; 34 ( 5 ): 463 – 472 . Google Scholar Crossref Search ADS PubMed 14. Pinto BM , Rabin C , Abdow S , Papandonatos GD . A pilot study on disseminating physical activity promotion among cancer survivors: A brief report . Psychooncology . 2008 ; 17 ( 5 ): 517 – 521 . Google Scholar Crossref Search ADS PubMed 15. Anderson ND , Damianakis T , Kröger E , et al. ; BRAVO Team . The benefits associated with volunteering among seniors: A critical review and recommendations for future research . Psychol Bull . 2014 ; 140 ( 6 ): 1505 – 1533 . Google Scholar Crossref Search ADS PubMed 16. Jenkinson CE , Dickens AP , Jones K , et al. Is volunteering a public health intervention? A systematic review and meta-analysis of the health and survival of volunteers . BMC Public Health . 2013 ; 13 : 773 . Google Scholar Crossref Search ADS PubMed 17. Woodall J , White J , South J . Improving health and well-being through community health champions: A thematic evaluation of a programme in Yorkshire and Humber . Perspect Public Health . 2013 ; 133 ( 2 ): 96 – 103 . Google Scholar Crossref Search ADS PubMed 18. Trujillo G , Aguinaldo PG , Anderson C , et al. Near-peer STEM mentoring offers unexpected benefits for mentors from traditionally underrepresented backgrounds . Perspect Undergrad Res Mentor . 2015 ; 4 ( 1 ). 19. Schwartz CE , Sendor M . Helping others helps oneself: Response shift effects in peer support . Soc Sci Med . 1999 ; 48 ( 11 ): 1563 – 1575 . Google Scholar Crossref Search ADS PubMed 20. Roman LA , Lindsay JK , Moore JS , Shoemaker AL . Community health workers: Examining the Helper Therapy principle . Public Health Nurs . 1999 ; 16 ( 2 ): 87 – 95 . Google Scholar Crossref Search ADS PubMed 21. Wallston KA , McMinn M , Katahn M , Pleas J . The helper-therapy principle applied to weight management specialists . J Community Psychol . 1983 ; 11 ( 1 ): 58 – 66 . Google Scholar Crossref Search ADS PubMed 22. Roberts LJ , Salem D , Rappaport J , Toro PA , Luke DA , Seidman E . Giving and receiving help: Interpersonal transactions in mutual-help meetings and psychosocial adjustment of members . Am J Community Psychol . 1999 ; 27 ( 6 ): 841 – 868 . Google Scholar Crossref Search ADS PubMed 23. Zemore SE , Kaskutas LA , Ammon LN . In 12-step groups, helping helps the helper . Addiction . 2004 ; 99 ( 8 ): 1015 – 1023 . Google Scholar Crossref Search ADS PubMed 24. Väänänen A , Buunk BP , Kivimäki M , Pentti J , Vahtera J . When it is better to give than to receive: Long-term health effects of perceived reciprocity in support exchange . J Pers Soc Psychol . 2005 ; 89 ( 2 ): 176 – 193 . Google Scholar Crossref Search ADS PubMed 25. Brown SL , Nesse RM , Vinokur AD , Smith DM . Providing social support may be more beneficial than receiving it: Results from a prospective study of mortality . Psychol Sci . 2003 ; 14 ( 4 ): 320 – 327 . Google Scholar Crossref Search ADS PubMed 26. Poulin MJ , Brown SL , Ubel PA , Smith DM , Jankovic A , Langa KM . Does a helping hand mean a heavy heart? Helping behavior and well-being among spouse caregivers . Psychol Aging . 2010 ; 25 ( 1 ): 108 – 117 . Google Scholar Crossref Search ADS PubMed 27. Poulin MJ , Brown SL , Ubel PA , Smith DM , Jankovic A , Langa KM . Does a helping hand mean a heavy heart? Helping behavior and well-being among spouse caregivers . Psychol Aging . 2010 ; 25 ( 1 ): 108 – 117 . Google Scholar Crossref Search ADS PubMed 28. Sokol R , Fisher E . Peer support for the hardly reached: A systematic review . Am J Public Health . 2016 ; 106 ( 7 ): 1308 . Google Scholar Crossref Search ADS 29. Lewin SA , Dick J , Pond P , et al. Lay health workers in primary and community health care . Cochrane Database Syst Rev . 2005 (1): CD004015 . 30. Riessman F . The helper therapy principle . Soc Work . 1965 ; 10 ( 2 ): 27 – 32 . 31. Konrath S , Brown S . The effects of giving on givers . In: Newman ML , Roberts NA , eds. Health and Social Relationships: The Good, the Bad and the Complicated . Washington, DC : APA Books ; 2013 . 32. Taylor SE . Adjustment to threatening life events: A theory of cognitive adaptation . Am Psychol . 1983 ; 38 ( 11 ): 1161 – 1173 . Google Scholar Crossref Search ADS 33. Ryan RM , Deci EL . Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being . Am Psychol . 2000 ; 55 ( 1 ): 68 – 78 . Google Scholar Crossref Search ADS PubMed 34. Pennebaker JW . Writing about emotional experiences as a therapeutic process . Psychol Sci . 1997 ; 8 ( 3 ): 162 – 166 . Google Scholar Crossref Search ADS 35. Rini C , Austin J , Wu LM , et al. Harnessing benefits of helping others: A randomized controlled trial testing expressive helping to address survivorship problems after hematopoietic stem cell transplant . Health Psychol . 2014 ; 33 ( 12 ): 1541 – 1551 . Google Scholar Crossref Search ADS PubMed 36. Pennebaker JW , Chung CK . Expressive writing and its links to mental and physical health . In: Friedman HS , ed. Oxford handbook of health psychology . New York, NY : Oxford University Press ; 2011 : 417 – 437 . 37. Mosher CE , Secinti E , Johns SA , et al. Examining the effect of peer helping in a coping skills intervention: A randomized controlled trial for advanced gastrointestinal cancer patients and their family caregivers . Qual Life Res . 2017 . (epub ahead of print). 38. Lepore SJ , Buzaglo JS , Lieberman MA , Golant M , Greener JR , Davey A . Comparing standard versus prosocial internet support groups for patients with breast cancer: a randomized controlled trial of the helper therapy principle . J Clin Oncol . 2014 ; 32 ( 36 ): 4081 – 4086 . Google Scholar Crossref Search ADS PubMed 39. Matthews BA , Baker F , Hann DM , Denniston M , Smith TG . Health status and life satisfaction among breast cancer survivor peer support volunteers . Psychooncology . 2002 ; 11 ( 3 ): 199 – 211 . Google Scholar Crossref Search ADS PubMed 40. Sheppard VB , Wallington SF , Willey SC , et al. A peer-led decision support intervention improves decision outcomes in black women with breast cancer . J Cancer Educ . 2013 ; 28 ( 2 ): 262 – 269 . Google Scholar Crossref Search ADS PubMed 41. Rush CL , Darling M , Elliott MG , et al. Engaging Latina cancer survivors, their caregivers, and community partners in a randomized controlled trial: Nueva Vida intervention . Qual Life Res . 2015 ; 24 ( 5 ): 1107 – 1118 . Google Scholar Crossref Search ADS PubMed 42. Sheppard VB , Hicks J , Makambi K , Hurtado-de-Mendoza A , Demark-Wahnefried W , Adams-Campbell L . The feasibility and acceptability of a diet and exercise trial in overweight and obese black breast cancer survivors: The Stepping STONE study . Contemp Clin Trials . 2016 ; 46 : 106 – 113 . Google Scholar Crossref Search ADS PubMed 43. Kraschnewski JL , Hwang KO , George DR , Lehman EB , Sciamanna CN . Feasibility of utilising an all-volunteer workforce as a disruptive innovation for the US obesity epidemic . Obes Res Clin Pract . 2014 ; 8 ( 5 ): e488 – e496 . Google Scholar Crossref Search ADS PubMed © Society of Behavioral Medicine 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Translational Behavioral Medicine Oxford University Press

The science of peer support as applied to behavioral medicine and the care of individuals surviving with cancer: a commentary on “Peer mentors delivering a physical activity intervention for cancer survivors: effects among mentors by Pinto et al.”

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Abstract

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 [11] 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 [11] 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 [17], 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 [30], theories of social support processes [24, 31], cognitive adaptation theory [32], and social determination theory [33], 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 [34] and peer support writing [35]. 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 [36]. 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 [35]. 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 [35]; 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) [43]. 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 . Cancer Epidemiol Biomarkers Prev . 2016 ; 25 ( 7 ): 1029 – 1036 . Google Scholar Crossref Search ADS PubMed 3. de Moor JS , Mariotto AB , Parry C , et al. Cancer survivors in the United States: Prevalence across the survivorship trajectory and implications for care . Cancer Epidemiol Biomarkers Prev . 2013 ; 22 ( 4 ): 561 – 570 . Google Scholar Crossref Search ADS PubMed 4. Buffart LM , Kalter J , Sweegers MG , et al. Effects and moderators of exercise on quality of life and physical function in patients with cancer: An individual patient data meta-analysis of 34 RCTs . Cancer Treat Rev . 2017 ; 52 : 91 – 104 . Google Scholar Crossref Search ADS PubMed 5. Rogers LQ , Courneya KS , Anton PM , et al. Effects of a multicomponent physical activity behavior change intervention on fatigue, anxiety, and depressive symptomatology in breast cancer survivors: Randomized trial . Psychooncology . 2017 ; 26 ( 11 ): 1901 – 1906 . Google Scholar Crossref Search ADS PubMed 6. 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Journal

Translational Behavioral MedicineOxford University Press

Published: Nov 21, 2018

References

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