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Review Article
Systematic review of peer-support programs for people with cancer
Louisa M. Hoey
a
, Sandra C. Ieropoli
a
, Victoria M. White
a,
*, Michael Jefford
b,c
a
Centre for Behavioural Research in Cancer, The Cancer Council Victoria, Australia
b
Cancer Information and Support Service, The Cancer Council Victoria, Australia
c
Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
Received 20 July 2007; received in revised form 21 November 2007; accepted 23 November 2007
Abstract
Objective: To identify models of peer support for cancer patients and systematically review evidence of their effectiveness in improving
psychosocial adjustment.
Methods: CINAHL (Cumulative Index to Nursing and Allied Health Literature), MEDLINE and PsychINFO databases were used to identify
relevant literature published from 1980 to April 2007. Data on characteristics of the peer-support program, sample size, design, measures, and
findings were extracted and papers were also rated with respect to research quality (categories ‘poor’, ‘fair’ or ‘good’).
Results: Forty-three research papers that included data from at least 1 group were reviewed in detail, including 26 descriptive papers, 8 non-
randomized comparative papers, and 10 papers reporting eight randomized controlled trials (RCTs). Five models of peer support were identified:
one-on-one face-to-face, one-on-one telephone, group face-to-face, group telephone, and group Internet.
Conclusion: Papers indicated a high level of satisfaction with peer-support programs; however, evidence for psychosocial benefit was mixed.
Practice implications: One-on-one face-to-face and group Internet peer-support programs should be given priority when considering ways to offer
peer support. Nevertheless, the other models discussed in this review should not be dismissed until further research is conducted with a wide range
of cancer populations.
#2007 Elsevier Ireland Ltd. All rights reserved.
Keywords: Peer support; Cancer; Systematic literature review
1. Introduction
A cancer diagnosis is a major stressor that can lead to
physical, emotional and social crises [1–3]. As a result, many
cancer patients experience a range of psychosocial difficulties
following diagnosis, including depression, anxiety, loneliness,
uncertainty and loss of control, decreased self-esteem,
disruptions to relationships, and fears about cancer recurrence
[4–8].
Social support has been identified as an important
contributor to general well-being that buffers the impact of
stressful experiences, including those related to physical illness
[9–11]. It is a multidimensional construct that includes the
provision of emotional, informational or instrumental support
[10,11]. In the cancer setting, it can be offered in a variety of
forms, including psychotherapeutic programs such as suppor-
tive expressive group therapy [12–14], educational programs
such as the Living With Cancer Education Program [15] and
peer-support programs such as Reach to Recovery [16,17] and
Man to Man [18]. While each of these interventions provides
support to cancer patients, they differ in some respects. In
psychotherapeutic programs a trained therapist conducts
therapy with patients (e.g., learning how to express and
manage emotions), while in educational programs a health
professional provides expert knowledge on cancer. While these
approaches have gained support in the literature [8,19–22], the
focus of this review is on peer support. Peer-support programs
may adopt certain aspects of psychotherapeutic programs (e.g.,
discussing emotions) and educational programs (e.g., providing
cancer information), but they differ in that no therapy is
conducted and the focus is not on providing education to the
patient.
Peer support refers to support offered to people with cancer
by people who have also experienced cancer [23]. Sharing
www.elsevier.com/locate/pateducou
Patient Education and Counseling 70 (2008) 315–337
DOI of original article: 10.1016/j.pec.2007.08.005.
* Corresponding author at: Centre for Behavioural Research in Cancer, The
Cancer Council Victoria, 1 Rathdowne Street, Carlton, Victoria 3053, Australia.
Tel.: +61 3 9635 5197; fax: +61 3 9635 5380.
E-mail address: Vicki.White@cancervic.org.au (V.M. White).
0738-3991/$ – see front matter #2007 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.pec.2007.11.016
Author's personal copy
experiences is the essence of peer support and enables a peer to
offer experiential empathy, something generally beyond the
scope of health professionals [24]. Dennis [25] described
emotional, informational and appraisal support as core
attributes of peer support, with the mutual identification,
shared experiences and sense of belonging developed through
peer support thought to impact psychological outcomes
positively. Two different theoretical models have been
suggested to describe the mechanisms by which peer support
may increase well-being. The direct effect model proposes that
peer support directly affects health outcomes by decreasing
feelings of isolation, encouraging health behaviours, promoting
positive psychological states and providing information. The
alternative model is guided by Lazarus and Folkman’s theory
[26] and suggests that peer support buffers the impact of stress
on health by reframing threat appraisals and improving coping
responses and behaviours.
Peer-support programs have been found to improve
satisfaction with medical care; personal relationships and
social support [27], increase a sense of belonging [28,29] and
improve mood [4,25]. However, several studies have also found
adverse outcomes, including failed social attempts, reinforce-
ment of poor behaviours and diminished feelings of self-
efficacy [25,30]. Two recent reviews assessing the effectiveness
of peer-support programs have concluded that participants
benefit from these programs; however, both comment upon a
paucity of well-designed studies [8,20].
There are a number of different models for the delivery of peer
support, including one-on-one, group, telephone and Internet
services. Macvean et al. (2007) examined the literature
describing one-to-one support programs for individuals with
cancer; however, as the focus of that review was volunteer-based
programs it included both peer and non-peer-support programs
[31]. To date there has been no systematic review comparing the
effectiveness of different peer-support models. The current
systematic literature review aims to identify the different models
of peer support described in the literature for people with cancer,
and examine the research assessing their effectiveness.
2. Methods
2.1. Search protocol
An extensive search of the published literature was
undertaken using electronic databases CINAHL (Cumulative
Index to Nursing and Allied Health Literature), MEDLINE and
PsychINFO, for the period 1980 to April 2007 with the search
terms: cancer or neoplas$ or oncology$ and peer or peer
support or peer and support or support group$ or support
program$ or group psychosocial support or self-help or visitor$
or survivor support. Reference lists were searched and key
researchers contacted to identify additional publications.
2.2. Paper inclusion and exclusion criteria
The inclusion criteria were: (1) written in English; (2)
described a specific program where peers provided direct
support to people with cancer; (3) peer had been diagnosed
and/or treated for cancer; and (4) primary purpose of the
program was to provide support to cancer patients. Papers
meeting any of the following exclusion criteria were
eliminated: (1) not a specific peer-support program; (2)
focused on children or adolescents; (3) educational or
therapeutic course run by professionals (including supportive
expressive therapy); (4) not primarily focused on peer support,
i.e., peer support was one of many components of the program;
(5) the peer support was for someone other than the person with
cancer (e.g., carer or friend); (6) the paper did not describe the
program in sufficient detail; (7) how the peer provided support
could not be determined; (8) could not determine if the person
giving support had experienced cancer; (9) editorial or letter
about a program; and (10) first-person account of an
experience.
2.3. Paper selection
A three-phase selection process was adopted. Author B
examined the titles, then abstracts, for their applicability
according to the inclusion and exclusion criteria. All papers
that appeared eligible were obtained and distributed between
authors A and B, who independently examined each
according to the selection criteria. The researchers discussed
papers considered ‘borderline’ for inclusion until consensus
was reached. If two papers presented the same dataset with
no new information supplied, only the earlier paper was
retained.
2.4. Paper classification and data extraction
Selected papers were classified independently by authors
A and B into one of the following pre-determined categories:
non-research theoretical or service usage (papers describing
a proposed model or specific program and papers that
contained no data apart from service usage data); one group
descriptive (describing a program with data collection,
one group only and no experimental design); non-randomized
comparative studies; and randomized controlled trials
(RCT).
Data were extracted from eligible papers about the peer-
support program (e.g., mode of delivery, peer or professionally
supervised, program members, cancer type, the nature of peer
support, and specific information about the peers and support
recipients) as well as details of the research (e.g., sample size,
control or comparison group, type of data collected, measures,
and findings).
2.5. Assigning program description review rating and
research quality ratings
Criteria for assessing paper quality were developed with
reference to the CONSORT (Consolidated Standards of
Reporting Trials) Statement checklist [32], the Program
Evaluation Standards [33] and the data collection checklist
for the Cochrane Effective Practice and Organisation of Care
L.M. Hoey et al. / Patient Education and Counseling 70 (2008) 315–337316
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Review Group [34]. We adopted this approach as many
of the selected papers reported on community-developed
programs and only a small proportion of the papers were
RCTs.
The criteria were tested on 50% of the papers to determine
their suitability. The criteria checklist assessed the amount of
information provided about the program, support recipients,
peers and research methodology (see Appendix A for
checklist). Papers were awarded one point for every item
satisfied; points were summed to give two sub-scores: a
program description rating and a research quality rating.
Higher ratings indicated more comprehensive descriptions and
more rigorous methodologies. We acknowledge that other
design issues (e.g., recruitment bias, blinding of assessment,
protection against contamination) are important criteria in
assessing internal validity and quality of a study and could have
been included in our checklist. However, as few papers
presented information about these issues, we opted for more
general design elements such as inclusion of a control group,
randomization, and timing of assessments in relation to the
intervention.
2.5.1. Program description rating
Program description ratings included three sections.
The first section (12 points) focused on the program,
including delivery mode, type of support, duration and
frequency of support, contact documentation, and peer
training. The second section (eight points) focused on the
peer description, including demographics, disease status
(survivor or current patient) and the peer recruitment
process. The third section (10 points) focused on the support
recipient description, including their demographics and
diagnosis. For models where support recipients and peers
were the same people (i.e., support groups), points were
awardedinboththesecondandthirdsectionsforeach
element included when describing group members. Each
paper received a rating up to 30 points and quality was
classified as: good (21–30 points), fair (11–20 points) and
poor (10 points and lower).
2.5.2. Research quality ratings
Research quality ratings focused on methodology, data
analysis, and results of the study (e.g., randomized assignment,
clear description of measures, pre-intervention measures, post-
intervention measures, description of differences or similarities
of each group). A maximum of 13 points could be obtained and
papers were classified as: good (10–13 points), fair (5–9 points)
and poor (0–4 points).
2.5.3. Author agreement in classifications and quality
ratings
Authors A and B independently classified each eligible
paper into one of the four categories with 100% agreement
achieved. Seventeen papers were randomly selected for double
coding of program description quality and research quality. A
mean agreement of 96% (range = 90–100%) and 92%
(range = 69–100%) was achieved, respectively.
3. Results
3.1. Overview—paper selection and classification
A total of 2945 unique published papers were identified. An
additional seven papers were recommended by key researchers
in the field, producing a final count of 2952 papers reviewed at
the title phase. Four hundred and thirty papers clearly irrelevant
(for example, they focused on children or reported a cancer
treatment trial) were eliminated. Abstracts for the remaining
2522 papers were examined and papers not meeting the
inclusion criteria were eliminated (n= 2350). The remaining
172 papers were read independently by authors A and B; 60
papers met the criteria, including 15 non-research theoretical,
26 descriptive, 9 non-randomized comparative, and 10 papers
reporting on 8 RCTs. As two non-randomized comparative
papers described the same dataset with no new information
provided, only one was retained. The 44 research papers are
reviewed in detail.
Table 1 describes the programs reported in the papers
reviewed. Five models of peer support were identified: one-on-
one face-to-face, one-on-one telephone, group face-to-face,
group telephone and group Internet. Tables 2–4 summarize the
salient research information of each eligible descriptive, non-
randomized comparative and RCT paper, respectively.
3.2. Papers with one group descriptive data
3.2.1. One-on-one face-to-face
Four papers presented data describing one-on-one, face-to-
face peer-support programs; each paper described a breast
cancer-specific program [4,35–37]. Data were mainly qualita-
tive and suggested that participants’ sense of isolation
decreased and that sharing experiences with peers gave a
new perspective and increased confidence.
3.2.2. One-on-one telephone
The two papers describing these sort of programs were
cancer-specific [30,38]. Giese-Davis et al. [30] evaluated a 6-
month peer counseling intervention for women with breast
cancer and reported improvements for patients on trauma
symptoms, emotional well-being, cancer self-efficacy and
desire for information. One paper [38] focused on a peer-
training program for an orthopedic oncology peer-support
program. Results suggested that training improved empathy,
listening and voice expression skills.
3.2.3. Group face-to-face
Nine papers presented data relating to face-to-face support
groups [18,39–46]. The majority described groups for specific
cancers; while some programs were peer-facilitated, others
were professionally facilitated. Overall, the quantitative and
qualitative results indicated that participants were satisfied with
their experiences in face-to-face support groups. Benefits
included feeling happier and more relaxed, receiving practical
and emotional support, and experiencing a sense of comfort and
camaraderie.
L.M. Hoey et al. / Patient Education and Counseling 70 (2008) 315–337 317
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Table 1
Program details of papers reviewed
Model of peer support Author, year Program start, location
and organizers
Participants Peer training/
supervision
Support location
and duration
Documented
contact
Program
rating
(out of 30)
a
One group descriptive studies
One-on-one,
face-to-face
Cameron et al., 1997 [36] 1972, Canada, not-for-profit Women with breast cancer Neither indicated Home, hospital, public
area, individualised
duration
Not indicated 8
Carlsson et al., 2005 [35] Year not indicated,
Sweden, not-for-profit
Women with breast cancer Yes—training/
supervision
not indicated
Not indicated Not indicated 12
Dunn et al., 1999 [4] Year not indicated,
Australia, not-for-profit
Women with breast cancer Yes—training/
supervision not
indicated
Hospital/treatment
centre, 3 weeks
Not indicated 13
Sutton et al., 2006 [37] Year not indicated, USA,
university and hospital
Women with breast cancer Neither indicated Mutually agreed place
(usually person with
cancer’s home), two
times per week; 8 weeks
Yes 2 6
One-on-one,
telephone
Giese-Davis et al.,
2006 [30]
Year not indicated, USA,
university and hospital
Women with breast cancer Yes—training/Yes Location not indicated,
One to four times per
week; 3–6 months
Yes 2 8
Smith et al., 1998 [38] Year, country and
organization not indicated
Cancer survivors who
received orthopaedic
rehabilitation
Yes—training/
supervision not
indicated
Location not indicated,
individualised duration
Yes 1 2
Group,
face-to-face
Cope et al., 1995 [39] Year and country not
indicated, hospital
Women with breast cancer Neither indicated Location not indicated,
1 h per week
Not indicated 17
Coreil et al., 1999 [18] 1990, USA, not-for-profit Men with prostate cancer Yes—training/
supervision not
indicated
Neither indicated Not indicated 19
Maisak et al., 1981 [40] 1976, USA, not-for-profit People undergoing or
completed lengthy cancer
therapy
Yes—training/
supervision
not indicated
Location not described,
monthly
Not indicated 20
Matsunaga et al., 2004 [41] 1993, USA, Community
group
Men with prostate cancer Neither indicated Public area, monthly Not indicated 18
Oliviere et al., 1996 [42] Year not indicated,
UK, workplace
Women with breast cancer Training not
indicated/Yes
Workplace, 1 h
per month; ongoing
Not indicated 17
Plant et al., 1987 [43] Year not indicated,
England, hospital
People with cancer Neither indicated Hospital, 1 h per month Not indicated 13
Smith et al., 2002 [44] 1994, USA, not-for-profit Men with prostate cancer Neither indicated Neither indicated Not indicated 13
Yaskowich et al., 2003 [45] Year not indicated,
Canada, not-for-profit
Women with breast cancer
45 years, women with
breast cancer 45 years,
patients with brain tumours,
people with any cancer
diagnosis
Neither indicated Location not indicated,
monthly
Not indicated 15
Zeigler et al., 2004 [46] 1999, USA, hospital Women with breast cancer Neither indicated Location not indicated,
2 h meetings fortnightly
Not indicated 21
L.M. Hoey et al. / Patient Education and Counseling 70 (2008) 315–337318
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Group, telephone Curran et al., 1998 [47] 1997, Canada, university
and not-for-profit
Women with breast cancer Neither indicated Educational institutions,
hospitals, medical clinics,
biweekly; 2 months
Not indicated 17
Reed, 2004 [48] 1996, UK, not-for-profit Women with breast cancer Neither indicated Home, 1 h per week; 8 weeks Not indicated 12
Solberg et al., 2003 [49] Year not indicated,
Canada, university
Women with breast cancer Neither indicated Health-care, educational and
community centres, duration
not indicated
Not indicated 14
Group, Internet Gustafson et al., 1993 [50] Year not indicated,
USA, University
Women with breast cancer Neither indicated Home, ongoing, available 24 h Not indicated 18
Hoybye et al., 2005 [54] 1999, Scandinavia,
organization not indicated
Women with breast cancer Neither indicated Location not indicated,
available 24 h; ongoing
Not indicated 19
Klemm et al., 1998 [52] 1996, country and
organization not indicated
People with colorectal cancer Neither indicated Location not indicated,
ongoing
Not indicated 10
Lieberman et al., 2003 [56] Year not indicated, USA,
university
Women with breast cancer Training not
indicated/Yes
Home, 1 per week; 16 weeks Not indicated 20
Sharf, 1997 [51] Year not indicated, Canada,
University
Women with breast cancer Neither indicated Location not indicated,
ongoing, available 24 h
Not indicated 8
Shaw et al., 2000 [5] Year not indicated, USA,
university
Women with breast cancer Neither indicated Home, available 24 h; ongoing Not indicated 17
Weinberg et al., 1995 [53] 1993, USA, University Women with breast cancer Neither indicated Home, available 24 h; 1 year Not indicated 19
Weinberg et al., 1996 [55] 1993, USA, University Women with breast cancer Neither indicated Home, available 24 h; 1 year Yes 21
Non randomized comparative studies
One-on-one,
face-to-face
Ashbury et al., 1998 [27] 1972, Canada, not-for-profit Women with breast cancer Neither indicated Not indicated Not indicated 11
Geiger et al., 2000 [57] 1994, USA, community group Women with breast cancer Yes—training/
supervision
not indicated
Location not indicated,
minimum weekly contact;
minimum 1 year
Yes 1 4
Rankin et al., 2004 [58] Year not indicated, Australia,
organization not indicated
Women with breast cancer Yes—training/
supervision
not indicated
Neither indicated Not indicated 12
Rogers et al., 1985 [17] 1952, USA, not-for-profit Women with breast cancer Yes—training/
supervision
not indicated
Hospital, 10–60 min Not indicated 13
Group, face-to-face McGovern et al., 2002 [59] Year not indicated, Ireland,
university and hospital
Men with prostate cancer Neither indicated Hospital, 1.5 h per month;
ongoing
Not indicated 18
Group, Internet Klemm et al., 1999 [62] Year, country and organization
not indicated
Women with breast cancer,
men with prostate cancer,
men and women with cancer
Neither indicated Home, ongoing Not indicated 7
McTavish et al., 2003 [60] Year not indicated, USA,
university
Women with breast cancer Neither indicated Home, available 24 h; ongoing Not indicated 15
Sullivan, 2003 [61] Year not indicated, USA,
organization not indicated
Women with ovarian cancer,
men with prostate cancer
Neither indicated Location not indicated,
ongoing
Not indicated 9
Randomized controlled studies
One-on-one,
face-to-face
Weber et al., 2004 [63] Year, country and organization
not indicated
Men with prostate cancer
who had radical prostatectomies
Yes/supervision
not indicated
Public area, eight meetings
over 8 weeks
Yes 2 1
One-on-one,
telephone
Houts et al., 1986 [64] 1982, USA, Hospital Women treated for
gynaecological cancer
Neither indicated Location not indicated,
three contacts over
10 weeks
Yes 1 6
L.M. Hoey et al. / Patient Education and Counseling 70 (2008) 315–337 319
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Table 1 (Continued )
Model of peer support Author, year Program start, location
and organizers
Participants Peer training/
supervision
Support location
and duration
Documented
contact
Program
rating
(out of 30)
a
Rudy et al., 2001 [65] Year, country and organization
not indicated
People with melanoma
undergoing immunotherapy
Yes—training/
supervision not
indicated
Location not described,
two required contacts
plus additional if
needed, 4–6 weeks
Yes 1 8
Group, face-to-face Helgeson et al., 1999 [67] Year not indicated, USA,
organization
not indicated
Women with breast cancer Yes—training/
supervision not
indicated
Location not indicated,
1 h per week; 8 weeks
plus 3 monthly meetings
Not indicated 20
Helgeson et al., 2000 [70] Year not indicated, USA,
organization
not indicated
Women with breast cancer Yes—training/
supervision not
indicated
Location not indicated,
1 h per week; 8 weeks
Not indicated 18
Helgeson et al., 2001 [66] Year not indicated, USA,
organization
not indicated
Women with breast cancer Neither indicated Location not indicated,
1 h per week; 8 weeks
Not indicated 20
Jacobs et al., 1983 [68] Year not indicated, USA,
organization
not indicated
People with Hodgkin’s disease Neither indicated Location, not indicated,
1.5 h per week; 8 weeks
Not indicated 20
Vos et al., 2004 [69] Year not indicated, Netherlands,
organization not indicated
Women with breast cancer Neither indicated Location not indicated,
2.5 h per week; 12-weeks
then 1 meeting at 1 month
post and 2 months post
Not indicated 20
Group, Internet Gustafson et al., 2001 [72] Year not indicated, USA,
University
Women with breast cancer Neither indicated Home, 6 months,
available 24 h
Not indicated 18
Winzelberg et al., 2003 [71] Year not indicated, USA,
organization not indicated
Women with breast cancer Neither indicated Home, available
24 h; 12 weeks
Not indicated 19
a
See text for description of program rating scoring.
L.M. Hoey et al. / Patient Education and Counseling 70 (2008) 315–337320
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Tab le 2
Research papers: papers with one group descriptive data
Models of
peer support
Paper reviewed Design Qualitative/
quantitative
Unit of analysis Measures Number and timing of
data points and timing
of intervention
Data reported Key findings Research
rating
(out of 13)
a
Cochrane
criteria
b
One-on-one,
face-to-face
Cameron et al.,
1997 [36]
Descriptive—perceived
objectives and benefits
of the program
Quantitative Fourteen women with
breast cancer. 23 peers
Interviews One data point: a few
months to several
years after program
participation
Experiences and
benefits of program
participation
Benefits included: provision
of information, support,
understanding, empathy,
hope, encouragement
and reassurance and
volunteers who are
non-judgemental,
non-threatening,
and non-medical.
Preference for contact
between diagnosis and
treatment
5No
Carlsson et al.,
2005 [35]
Descriptive—experiences
peer support
Qualitative Eight women with breast
cancer
Interviews One data point after
one to five contacts
with peers (within
4 years post-diagnosis)
Themes about
experiences of
peer support
1. Shared experiences
give new perspectives
on having cancer.
2. Feelings of isolation
are part of the identity
of the illness. 3.
Relations with others
enable self-help.
Important for programs
to offer volunteers
training prior to providing
peer support
5No
Dunn et al.,
1999 [4]
Descriptive—perceived
benefits of the program
Quantitative
and qualitative
Two hundred and twenty-
three women with breast
cancer
Quant: Own scale. Qual:
focus groups
One data point after
service participation
(within 4 months
of surgery)
Perceptions of
the helpful and
unhelpful aspects
of the program
Program perceived to be
very helpful and women
reported feeling less
anxious after visit. Bond
of common experience
contributed to decrease
in social isolation,
increase in optimism
about the future and
reassurance about
personal reactions and
femininity. Support
should be provided
early in post-operative
period. Some reported
having an increase in
fears about the future
7No
Sutton et al.,
2006 [37]
Descriptive—experiences
of the program
Qualitative Thirty -three women with
newly diagnosed breast
cancer. 33 peers
Content analyses of log
of contacts and meaningful
observations journal.
Own scale
Baseline and post-
intervention, logs
of contact completed
after each contact
Interpersonal
relationship
between dyads,
themes discussed,
changes in perceived
support from others,
health issues,
changes of priorities
and faith
Most contact by phone
rather than in person.
While both survivor and
newly diagnosed women
expected mutual support,
newly diagnosed woman
received more support than
did the survivors. However,
most survivors were happy
with providing this level
of support. Survivors
provided informational
and emotional support.
7No
L.M. Hoey et al. / Patient Education and Counseling 70 (2008) 315–337 321
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Table 2 (Continued )
Models of
peer support
Paper reviewed Design Qualitative/
quantitative
Unit of analysis Measures Number and timing of
data points and timing
of intervention
Data reported Key findings Research
rating
(out of 13)
a
Cochrane
criteria
b
One-on-one,
telephone
Giese-Davis
et al., 2006 [30]
Descriptive—impact of
program on emotional
regulation
Quantitative Twenty-nine women
with breast cancer. 25 peers
CES-D, PCL-C, FACT-B,
CBI, Medical Interaction
Scale, CARES, BCRQ,
CECS, WAI, SESES-C
Three data points:
baseline, 6 and
12 months post-
program comme
ncement
Depression, cancer-
related trauma
symptoms, quality
of life, cancer self-
efficacy, suppression
of affect, doctor-
patient relationship,
problems encountered
by cancer patients,
breast cancer resources,
adjustment, self-efficacy,
description of contact and
feelings during the contact
Women with breast
cancer: significant
improvement in trauma
symptoms, emotional
well-being, cancer
self-efficacy, and
desire for information
on breast cancer
resources. Peers:
maintained baseline
levels in outcome
measures, increased
dissatisfaction with
their interactions with
their medical team and
increased emotional
suppression
9No
Smith et al.,
1998 [38]
Descriptive—experiences
of the program
Qualitative People with cancer
and peers (N unclear)
Attending behaviours
scale, empathy behaviour
Scale, own items for
program evaluation
Peers assessed before
and after training.
Peers and people
with cancer completed
a form after each
contact. People with
cancer completed an
evaluation after each
contact (no baseline for
people with cancer)
People with cancer and
peers experience with
the program. Satisfaction
as reported by people
with cancer
Peers found training
helpful and satisfactory.
The evaluations
completed by newly
diagnosed patients
indicated that the
program was:
1. a positive experience;
2. associated with an
increased sense of
confidence to succeed
in their rehabilitation
4No
Group,
face-to-face
Cope et al.,
1995 [39]
Descriptive—perceived
functions of the program
Qualitative Fifteen women with breast
cancer. 1 facilitator
Observation of 10 group
meetings. 2 interviews
Data collection continued
until repetition of data
occurred without any
new themes
Perceptions of women
with breast cancer about
the functions of a breast
cancer support group
Three main functions
of the breast cancer
support group:
1. exchange information;
2. share the illness experience;
3. provide strength
4No
Coreil et al.,
1999 [18]
Descriptive—characteristics
of group and members
Quantitative Thirty-eight support groups:
399 men with prostate
cancer. 6 women attending
the group. 41 facilitators
Research devised self
report questionnaire
One data point at
unknown time
after service
participation
Characteristics of
support groups,
facilitator profile,
member profile
Typical format of
groups included
education plus
sharing personal
experiences between
members. Facilitators
and participants tended
to be retired and from
well-educated
background, attending
the group after being
treated for prostate
cancer. High levels
of participant satisfaction
were reported. Vast
majority of facilitators
were peers; they reported
needing training and support
5No
Maisiak et al.,
1981 [40]
Descriptive—perceived
benefits of the program
Quantitative
and qualitative
Quant: 139 people with
cancer and family/friends.
Qual: 5 people with cancer
and family/friends
Quant: Own scale.
Qual: Interviews
Quant: 1 data point at
unknown time after
service participation
Qual: 1 data point at
unknown time after
service participation
Experiences and
benefits of program
participation
Benefits: improved ability
to cope with cancer,
increased cancer knowledge,
and improved family
relationships and friendships
5No
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Matsunaga et al.,
2004 [41]
Descriptive—perceived
benefits of the program
Qualitative Twenty-four men
with prostate cancer
Interviews with people
with cancer
One retrospective
interview per participant.
Timing of data points and
intervention unknown
Views of people with
cancer on perceived
benefits and aspects
that contributed to the
group’s success
Benefits: comfort,
camaraderie, practical
information, enhanced
coping, and opportunity
to talk. Successes
attributed to leadership
and group members
4No
Oliviere et al.,
1996 [42]
Descriptive—perceived
benefits of the program
Qualitative Nine women with breast
cancer
Interviews One retrospective
interview per participant
Experiences of the
program
Women attended the
group for support connected
to the workplace. They
were satisfied with the
group and appreciated
that work issues could
be discussed
5No
Plant et al.,
1987 [43]
Descriptive—experiences
of the program
Quantitative Sixty people with cancer
and family/friends
Own scale One retrospective
questionnaire at least
3 months after first
attendance
Experiences of the
support group reported
by people with cancer
and family/friends
Participants received at
least some (if not all)
the information they
wanted through the
program. Most felt
happier, more relaxed
and able to cope after
attending
6No
Smith et al.,
2002 [44]
Descriptive—service usage
and experiences of the program
Quantitative
and qualitative
Quant: 112 men with prostate
who had participated in the Man
to Man program, 44 urologists.
Qual: 4 men with prostate cancer
who had not participated in
support groups
Quant: Interviews
Qual: Focus groups
One data point at
unknown time in
relation to intervention
Quant: patients:
experiences of the
program Quant:
urologists: awareness
of the program Qual:
reasons why these men
do not seek support
through support groups
Men with cancer
valued the treatment
information,
physician presentations,
and social aspects
of the program.
Majority of
clinicians were
aware of the program
but most did not know
the services it offered.
The focus group
indicated that some
men do not attend
the program as they
prefer other sources
of social support
5No
Yaskowich
et al., 2003 [45]
Descriptive—experiences
of the program
Qualitative Twenty-three people with
cancer
Interviews One data point at
unknown time after
intervention
Experiences of the
program
The support group
allowed people with
cancer to talk safely,
demystify the
unknown, make
decisions, have hope,
and find a space to
work through emotions
4No
Zeigler et al.,
2004 [46]
Descriptive—experiences
of the program
Quantitative
and qualitative
Ten women with breast
cancer. 2 group facilitators
Common Journey Initial
interview form. Common
Journey end of year form.
Common Journey group
voices form. Facilitator
voices form
Four data points: first
meeting of the group,
last meeting of the
group, and 6 and
12 months post-
participation
Cancer-related questions,
open-ended questions to
reflect four adaptive modes
of the Roy Adaptation
Model of Nursing -
responses coded as
‘adaptive’ or ‘ineffective’
Majority of
participants provided
adaptive responses
(i.e., group goals
achieved) at the
initial and end of
year interview.
Combination of
information and
emotional support was
effective in meeting the
women’s needs. No statistical
tests to determine change in
responses, however frequency
scores suggested consistency
between initial and end of
year responses
6No
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Table 2 (Continued )
Models of
peer support
Paper reviewed Design Qualitative/
quantitative
Unit of analysis Measures Number and timing of
data points and timing
of intervention
Data reported Key findings Research
rating
(out of 13)
a
Cochrane
criteria
b
Group, Telephone Curran et al.,
1998 [47]
Descriptive- satisfaction
with program
Quantitative Seventeen women with
breast cancer
Own scale One data point at
unknown time after
service participation
Experience and satisfaction
with the program and
teleconferencing technology
Participants expressed
positive opinions about
the group. Majority
agreed that the group
addressed the need for
social support and
information on breast
cancer. Many indicated
that the program
helped them feel less
isolated and it made
them ‘feel good’.
Many indicated strong
interest in attending
future teleconferencing
sessions and agreed
that the sessions
should continue.
Disadvantages
included: sessions
were too short,
reluctance to speak
due to unfamiliarity
with the equipment,
lack of face-to-face
interaction and lack
of follow-up support
5No
Reed, 2004 [48] Descriptive –experiences
of the program
Unclear Women with breast
cancer (N unclear)
Not indicated One data point at
unknown time in
relation to intervention
Benefits and difficulties of
program participation
Vast majority of
participants felt the
main benefit was
talking to others in a
similar situation.
Some women reported
feeling more assertive
and confident talking
to health care professionals.
Difficulties in the group
included: the death of a
group member, not being
able to see other participants,
discussing disease progression
and hearing distress of
other members
3No
Solberg et al.,
2003 [49]
Descriptive- experiences
of the program
Qualitative Eleven women with
breast cancer
Interviews One data point at
unknown time in
relation to intervention
Perceptions of how
participants received
support through the
program
Four phases were identified:
1. Getting connected to the
network at different
sites and geographical
locations –sometimes
problematic. 2. Finding
a voice (how the women
asked questions or
responded). 3. Connecting
with others (comparing
with others, receiving
empathy). 4. Becoming
empowered (taking more
control and making lifestyle
changes)
5No
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Group, Internet Gustafson et al.,
1993 [50]
Descriptive—evaluation
of the program
Quantitative
and qualitative
Thirty women with
breast cancer
Quant: Own scale
Qual: telephone
interviews
Two data points:
6 months post-program
development and
1 year following
Experience and
satisfaction with the
program, value of
program, service
usage and topics
discussed during
groups
Program was rated as
extremely valuable in
providing members
with information,
support, understanding
and empathy, and
reducing fear, sense
of helplessness and
indifference. Support
group was the service
most often used.
Compared with the
possibility of having
a nurse or cancer
survivor to talk to,
most participants
preferred program
due to anonymity,
availability of system
at any time, and
comprehensiveness
6No
Hoybye et al., 2005 [54] Descriptive—effect on
perceived social isolation
Qualitative Fifteen women with
breast cancer
Face-to-face and
on-line interviews.
Content analysis of
messages posted
Interviews conducted
four months after
program involvement
Participant observation
occurred over 8-month
period
Program experiences,
personal breast cancer
stories, themes
discussed on
mailing list
Participation in the
internet support group
empowered women
through: 1. knowledge,
2. tears and laughter
from sharing
experiences, 3.
entering a new
social world, 4.
social intimacy
7No
Klemm et al., 1998 [52] Descriptive—service usage
and themes raised in groups
Qualitative Ninety-seven people
with colorectal cancer
Content analysis of
messages posted
Two data points:
4-day period and
6 months later over a
5-day period
General themes
discussed by support
group members
Eight main themes
identified: 1. information
seeking/giving on various
topics, 2. personal opinions,
3. encouragement/support,
4. sharing personal
experiences, 5. expression
of thanks for caring, help
given, support, sharing,
sending messages,
explanations, listening,
opinions, and informed
responses, 6. humour,
7. prayer, 8. miscellaneous
(e.g., problems related to
posting messages)
5No
Lieberman et al.,
2003 [56]
Descriptive—perceived
benefits of the program
Quantitative
and qualitative
Thirty-two women
with breast cancer
CES-D, PTGI, PAIN
scale, CECS, WAI,
Mini-MAC. Telephone
interviews
Three data points:
baseline (pre-intervention);
16-weeks later (program
completion); 1 month
following program
completion
Depression, positive
changes, pain,
suppression of affect,
regression of negative
affect, cancer-related
coping, satisfaction
with program
Participants demonstrated
a significant reduction in
depression and reaction
to pain, and an increase
in their experience of
positive changes.
However, the participants
demonstrated an increase
in emotional suppression.
Post-interview results
indicated that two-thirds
of patients found the group
to be beneficial
9No
L.M. Hoey et al. / Patient Education and Counseling 70 (2008) 315–337 325
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Table 2 (Continued )
Models of
peer support
Paper reviewed Design Qualitative/
quantitative
Unit of analysis Measures Number and timing of
data points and timing
of intervention
Data reported Key findings Research
rating
(out of 13)
a
Cochrane
criteria
b
Sharf, 1997 [51] Descriptive—experiences
of the program
Qualitative Not indicated Participant
observation
Participant observation
occurred over 10-month
period (program ongoing)
Topics discussed,
function of the program
for its members, quality
of conversations
Three major dimensions in
the messages: 1. exchange
of information, 2. social
support, 3. personal
empowerment. Perceived
differences between Internet
and face-to-face peer support:
availability of the list at all
times, diversity of people
who use the internet increases
experience/expertise of members,
lack of visual and tactile
communication can encourage
more uninhibited release
of feelings
4No
Shaw et al., 2000 [5] Descriptive—experiences
of the program
Qualitative Twelve women
with breast cancer
Semi-structured
interviews
One data point: during
program participation
(length of time parti
cipated in program
ranged from few
months to few years)
Experiences of program;
benefits and difficulties
of program participation
Three main themes identified:
1.Advantageous: anonymity,
equalized participation, support
without feeling self-conscious,
asynchronous nature, obtain
support at any time. 2. Motivation
for seeking support: lack of
understanding from family
members, stressed personal
relationships, providing support
to others. 3. Benefits: sense of
universality, reduces uncertainty,
anxiety, depression and stress,
sense of altruism, sense of
reward from helping others,
social comparison
6No
Weinberg et al.,
1995; 1996 [53,55]
Descriptive—experiences
of the program and
program feasibility
Quantitative
and qualitative
Six women with
breast cancer
Content analysis of
messages posted.
Own scale
Posting monitored
over 3-month period.
Scale completed at
program conclusion
Extent of use, themes
discussed and
participants’ perceptions
of helpfulness, universality,
group cohesion, instillation
of hope, altruism, and
catharsis of the group
Most participants quickly learned
how to use the program. On average,
each participant connected to the
bulletin board twice per week and
in total 158 connections were made.
The group was primarily used
to discuss medical and personal
concerns. Participants perceived
hope, group cohesion and universality
as primary therapeutic factors. These
three factors were also most related
to the perceived helpfulness of the
group
7 (1995),
6 (1996)
No
a
See text for description of research ratings.
b
Criteria for determining papers suitability for inclusion in Cochrane review [32].
L.M. Hoey et al. / Patient Education and Counseling 70 (2008) 315–337326
Author's personal copy
Table 3
Research papers: non-randomized comparative studies
Models of
peer support
Paper reviewed Design Qualitative/
quantitative
Unit of analysis Measures Number and timing of
data points and timing
of intervention
Data reported Key findings Research
rating (out
of 13)
a
Cochrane
criteria
b
One-on-one,
face-to-face
Ashbury et al.,
1998 [27]
Descriptive—compared
program and non-program
users
Quantitative Three hundred and sixty-
seven women with breast
cancer (175 program users,
192 non-users)
FLIC, FACT, Duke
Functional Social
Support
Questionnaire, own
scale
One data point: post-
intervention (timing after
intervention not indicated)
Various quality of
life domains. Program
satisfaction
Compared to non-users,
program participants had
better self-reported health
status, social support and
better relationship with
doctor. Over three-quarters
of program participants
reported that they were
satisfied with the program
8No
Geiger et al.,
2000 [57]
Descriptive—compared
people diagnosed at program
sites to those diagnosed at
non-program sites
Quantitative Three hundred and seven
women with breast cancer
(82 program users, 225
non-users)
Own scale One data point: post-
intervention, 4 months
post-diagnosis (timing
intervention participation
not indicated)
Program satisfaction Compared to non-users,
support group participants
reported significantly higher
satisfaction with breast
cancer care, pre-surgery
care, provision of
information and emotional
support
9No
Rankin et al.,
2004 [58]
Descriptive—population-based
survey comparing service users
and non-service users
Quantitative Five hundred and forty-four
women with breast cancer
(195 users, 349 non-users)
Own scale One data point: post-
intervention, between
6 and 12 months post-
diagnosis (timing after
service participation
not indicated)
Perceptions of care,
sources of support,
experiences with
program
Vast majority of women
who used the service said
that they would definitely
recommend it to other
women. Program provided
useful support. Meeting
women with similar
experiences reported to
be most beneficial aspect
of program
9No
Rogers et al.,
1985 [17]
Descriptive—compared
program users and people
receiving other forms of support
Quantitative Six hundred and fifty-two
women with breast cancer
(476 users, 176 non-users)
Interviews,
CES-D depression
scale, Delighted-
terrible well-being
scale
One data point: post-
intervention, between
6 and 16 months post-
surgery (timing after
service participation
not indicated)
Evaluation of the
program (e.g..
helpful/unhelpful)
Effect on emotional
and physical well-
being
Patients’ evaluations of the
program were positive and
visits perceived as helpful.
No significant differences
between groups on
emotional or physical
well-being
7 (for both papers) No
Group,
face-to-face
McGovern
et al., 2002 [59]
Controlled trial—compared
outcomes in people in peer-
support program with
control group
Quantitative Fifty-one men with prostate
cancer (14 in program,
37 in control group)
Mini-MAC,
Health survey
One data point: post-
intervention (timing
after intervention
not indicated)
Coping style and
quality of life
Compared to controls,
support group participants
were more likely to endorse
an ‘anxious preoccupied’
coping style. No difference
between groups in health-
related quality of life
7No
Group, Internet Klemm et al.,
1999 [62]
Descriptive—compared
Internet postings by gender
Qualitative One hundred and seventeen
postings from prostate
Internet support group;
126 posting from breast
Internet support group,
92 posting from a non-cancer
specific internet support group
Internet postings Consecutive posting
collected for each
group over 6-week
period
Themes discussed
by support group
members
The most frequent theme
for males was information
seeking and information
giving. The most frequent
theme for females was
personal experience
5No
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3.2.4. Group telephone
Three descriptive papers described telephone support groups
for women with breast cancer [47–49]. One paper indicated that
a professional facilitated the group; the other papers did not
describe the facilitator. All papers reported benefits from
participation that included feeling less isolated, receiving
empathy, empowerment, and increased assertiveness when
communicating with health professionals. Disadvantages
included a lack of follow-up support and not being able to
see other members.
3.2.5. Group Internet
Eight papers described Internet support groups [5,50–56].
All programs were breast cancer-specific, except one which
was colorectal cancer-specific [52]. Seven papers described a
bulletin board format where participants posted messages to
other group members at any time [5,50–55]. One paper
described a chat-room format [56] where participants and a
facilitator met online at a predetermined time to discuss cancer-
related issues. Overall, the results indicated that group Internet
peer support provided encouragement, empowerment, informa-
tion and a sense of cohesion.
3.2.6. Rating of the program description quality for one-
group descriptive papers
The program description quality ratings for these papers
ranged from 8 to 28, with a mean of 15.9 out of 30 (see Table 1).
The research quality ratings for these papers were fair (refer to
Table 2), ranging from 3–9 (mean = 5.5). No paper was eligible
for Cochrane review.
3.3. Non-randomized comparative studies
3.3.1. One-on-one face-to-face programs
Four comparative papers [17,27,57,58] examined one-on-
one face-to-face peer-support programs. None used a pre–post-
test design. Reach to Recovery was evaluated in two studies
[17,27] which indicated that users reported better social support
and better relationships with their doctors than non-users.
Participants reported that the program was helpful, with shared
experiences being the crucial aspect. However, Rogers et al.
[17] found no significant differences between users and non-
users on the psychological factors measured. Geiger et al. [57]
found that peer-support users were more positive about their
experience with medical staff and were less likely to want a
second opinion compared to non-users. Rankin et al. [58] found
that women perceived peer support as acceptable, with
participation related to provision of information about the
program.
3.3.2. Group face-to-face
One comparative study [59] explored the effectiveness of
face-to-face group support programs for men with prostate
cancer. This paper did not include a pre-intervention measure.
No significant differences in health-related quality of life were
found between users and non-users of the support group;
Table 3 (Continued )
Models of
peer support
Paper reviewed Design Qualitative/
quantitative
Unit of analysis Measures Number and timing of
data points and timing
of intervention
Data reported Key findings Research
rating (out
of 13)
a
Cochrane
criteria
b
McTavish et al.,
2003 [60]
Descriptive—compared
Internet postings by
cultural background
Qualitative One hundred and thirteen
women breast cancer
(86 Caucasian women,
27 women of colour)
Internet postings Postings selected
randomly over a
26-week period
Themes discussed
by support group
members
Women of colour used the
discussion group less than
Caucasian women. Women
of colour tended to focus
on breast cancer and
treatment issues while
Caucasian women focused
on daily life issues
7No
Sullivan,
2003 [61]
Descriptive—compared
Internet postings by gender
Qualitative One hundred and seventy
women with ovarian cancer.
213 men with prostate cancer
Internet postings Not clearly indicated Themes discussed
by support group
members
Males focused on information
sharing and avoiding
disclosure; in contrast, females
focused on emotional expression
and discussion of experiences
4No
a
See text for description of research ratings.
b
Criteria for determining papers suitability for inclusion in Cochrane review [32].
L.M. Hoey et al. / Patient Education and Counseling 70 (2008) 315–337328
Author's personal copy
Table 4
Research papers: randomized controlled trials
Model of
peer support
Paper reviewed Design Qualitative/
quantitative
Unit of analysis Measures Number and timing
of data points and
timing of intervention
Data reported Key findings Research
rating
(out of 13)
a
Cochrane
criteria
b
One-on-one,
face-to-face
Weber et al.,
2004 [63]
RCT—compared peer support
and usual care control
Quantitative Thirty men who had
recently undergone a
radical prostatectomy
(Program n= 15, control
n= 15)
Modified Inventory of
Socially Supported
Behaviours, SICPA,
GDS, UCLA Prostate
Cancer Index, The
Charlson Index
Three data points:
Baseline, 4 weeks
later and 8 weeks
later (program
completion)
Social support, self-
efficacy, depressive
symptomatology,
urinary and sexual
function/bother
Peer-support
participants
reported significantly
more social support
providers than control
participants. The majority
of participants found the
program worthwhile
13 Yes
One-on-one,
telephone
Houts et al.,
1986 [64]
RCT—compared 2 conditions:
(A) control—professional
support and (B) A plus peer
support
Quantitative Thirty-two women
beginning gynaecological
treatment (A:N = 18,
B:N = 14)
POMS, own scale
(assessed coping
behaviours)
Three data points:
Baseline, 6 weeks
and 12 weeks post-
intervention
Emotional distress and
coping behaviours
Condition B
participants
were more likely to
report that they had
changed their
relationships
with family members
than condition A
participants. This
was in the opposite
direction to what was
hypothesised. No
significant difference
in emotional distress
between participants in
condition A and B
at 6 or 12 weeks.
12 Yes
Rudy et al.,
2001 [65]
RCT—compared peer-support
program with wait listed control
group
Quantitative
and qualitative
Fifty-nine people with
melanoma (Program
n= 29, wait list n= 30)
29 peers
Social Support Survey,
evaluation surveys
completed by people
with cancer and peers
One data point: 1
week post-
intervention
Social Support Program
satisfaction
Peer-support participants
reported significantly
more social support
providers than control
participants. The majority
of participants found the
program worthwhile and
benefited from
informational
and emotional support
10 Yes
Group, face-
to-face
Helgeson et al.,
1999; 2000;
2001 [67,70,66]
RCT—compared 4 conditions:
A) education, B) peer discussion,
C) A and B, D) control
Quantitative Two hundred and fifty-
eight women with breast
cancer (A:N = 66,
B:N = 60, C:N = 66 and
D:N = 66)
SF-36 Six data points:
Baseline, 2 weeks,
6 months, 12 months,
2 years and 3 years
post-intervention
Health-related quality
of life
When data from 5 waves
of measurement were
averaged, there were no
significant differences
between peer discussion
group and control
on QOL measures
11 (for
all 3
papers)
Yes
Jacobs et al.,
1983 [68]
2 RCT studies: 1. compared
education group (A) with control
group (B) 2. compared peer-
support group (C) with control
group (D)
Quantitative Eighty-one people with
Hodgkin’s disease
(A:N = 21, B:N = 26,
C:N = 16 and D:N = 18)
CPBS Two data points:
baseline and 8
weeks later
(program
completion)
Psychological and social
functioning
No differences between
condition C participants
and control counterparts
on psychological or
social functioning
11 Yes
L.M. Hoey et al. / Patient Education and Counseling 70 (2008) 315–337 329
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Table 4 (Continued )
Model of
peer support
Paper reviewed Design Qualitative/
quantitative
Unit of analysis Measures Number and timing
of data points and
timing of intervention
Data reported Key findings Research
rating
(out of 13)
a
Cochrane
criteria
b
Vos et al.,
2004 [69]
RCT—compared 3 conditions:
(A) psychotherapy group, (B)
social support group and C)
wait list control group
Quantitative Sixty-nine women with
breast cancer (A:N = 15,
B:N = 19, C:N = 35)
Utrecht Coping List,
Health and Disease
Inventories, Social
Network Questionnaire,
POMS, EORTC QLQ-30
and Sickness Impact Profile
Two data points:
baseline and 12
weeks later
(program
completion)
Psychosocial adjustment,
social support, coping,
psychosexual functioning
and social adjustment
No significant between
group differences on
measures of psychosocial
adjustment. Significantly
higher levels of social
support perceived by
women in condition B
compared to other
conditions.
Women in condition
B used more palliative
coping
11 Yes
Group, Internet Gustafson et al.,
2001 [72]
RCT—compared people in
peer-support program with
control group
Quantitative Two hundred and forty-
six women with breast
cancer (Program n= 121,
control n= 125)
Social support scale,
unmet information need
scale, information
competence scale,
perception of involvement
in health care scale, comfort
with clinician scale, FACT-B
Three data points:
baseline, 2 and
5 months post-
intervention
Social and informational
support, participation
in health care, comfort
and confidence in
clinician, quality of life
Peer-support
participants scored
higher on social and
informational support
at post-intervention,
and higher participation
in health care at
2 months. No main
effects
were found for quality
of life
13 Yes
Winzelberg et al.,
2003 [71]
RCT—compared peer-support
program with wait listed control
Quantitative Seventy-two women with
breast cancer (Program
n= 36, wait list control
n= 36)
CES-D, PCL-C, STAI, PSS,
CBI, Mini-MAC, own scale
(assessed perceptions
of group experiences)
Two data points:
baseline and
12 weeks later
(program completion)
Depression, post-traumatic
stress, state anxiety,
global perceived stress,
coping behaviour,
adjustment to cancer
and program satisfaction
Significant between
group differences.
Improvement
on depression, perceived
stress and post-traumatic
stress for peer-support
participants compared to
control group. Participants
perceived a number
of benefits and satisfaction
from their participation
in the program
13 Yes
a
See text for description of research ratings.
b
Criteria for determining papers suitability for inclusion in Cochrane review [32].
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however, users were more anxiously preoccupied than non-
users.
3.3.3. Group Internet
Three comparative papers investigated group Internet peer-
support programs. One was breast cancer-specific [60], one had
an ovarian cancer specific and a prostate cancer-specific group
[61], and the third had specific breast and prostate cancer
groups as well as a mixed cancer group [62]. In general, the
papers suggested that interactions within Internet-based
support groups might differ depending on gender, diagnosis,
and cultural background.
3.3.4. Ratings of program description and research quality
for comparative papers
The average program description quality rating for the nine
comparative papers was 12.7 out of 30 (range: 7–18). The score
is lower than the previous category (refer to Table 5), largely
because papers provided insufficient detail regarding the
intervention. The research quality ratings of these papers were
fair (see Table 3), ranging from 4 to 9 out of 13 (mean = 6.7).
Although all papers used a comparison group, none involved a
pre–post-design or randomization; therefore none were eligible
for Cochrane review.
3.4. Randomized controlled trials
3.4.1. Overview
The 10 papers reporting on 8 RCTs are summarized in
Table 4. Follow-up time points ranged from 1 week to 2 years
post-intervention. We categorized follow-up as: immediate
(within 4 weeks of completing the intervention); medium term
(more than 1-month post-intervention completion and less than
2 years); and long term (at least 2 years post-intervention
completion).
3.4.2. One-on-one face-to-face
Weber et al. examined a one-on-one, face-to-face peer-
support program for men with prostate cancer [63]. Thirty men
were randomly allocated to usual care (control) or intervention
groups. The intervention matched men to a support partner who
was a long-term survivor of prostate cancer. Dyads met eight
times over an 8-week period to discuss problems encountered
after radical prostatectomy; outcome measures were completed
at 4 and 8 weeks. Self-efficacy increased from baseline to 8
weeks for the intervention group. Depression scores for the
intervention group were lower at 4 weeks but did not differ
between groups at 8 weeks.
3.4.3. One-on-one telephone
Two RCTs explored the effectiveness of one-on-one
telephone intervention programs [64,65]. In the trial by Rudy
et al. [65], people undergoing treatment for melanoma were
randomly allocated to control (n= 30) or intervention (n= 29)
consisting of two to four telephone contacts from peers.
Participants were followed up 1 week after treatment
completion and the telephone support program had ended.
Both groups completed a questionnaire, assessing the avail-
ability of social support but only at follow-up. Intervention
group patients generally reported about twice as many support
providers as control group patients. Psychological outcomes
such as depression or adjustment were not measured.
Houts et al. [64] reported findings from a trial that focused
on women with gynecological cancer (n= 32). In the
intervention arm, peer counselors contacted patients three
times (prior to hospitalization, and 5 and 10 weeks later) to
provide telephone support focusing on coping strategies.
Emotional distress was measured with the Profile of Mood
States at pre-intervention and immediate post-intervention.
There were no significant differences in emotional distress
levels between the intervention and control conditions post-
intervention. Intervention patients were significantly more
likely to report changes in their relationships with family
members. The authors were surprised at this result because the
intervention emphasized maintaining normal family relation-
ships.
3.4.4. Group face-to-face
Five papers reported the findings of three trials [66–70]
exploring the effectiveness of face-to-face group support
programs. Two trials focused on breast cancer patients
[66,67,69,70] and one focused on patients with Hodgkin’s
disease [68]. All papers included pre-intervention measures,
three reported immediate follow-up measures [68–70], one
reported medium-term follow-up [67], and another long-term
follow-up [66].
In the trial reported by Helgeson et al. [66,67,70], women
with breast cancer were randomly allocated to one of four
groups: education, peer discussion, education plus peer
discussion or control. The education program aimed to
disseminate information in a lecture format. Participants
attended eight professionally facilitated weekly meetings,
Table 5
Average quality ratings for each paper classification
Paper classification
Papers with one group
descriptive data
Non-randomized
comparative studies
RCTs
Number of papers 26 9 10
Descriptive review rating 15.9 12.7 18.7
Research quality rating 5.5 6.7 11.6
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followed by three monthly telephone calls from the facilitator.
The peer discussion intervention was aimed at providing
emotional support. Participants attended eight professionally
facilitated weekly meetings, followed by three additional
monthly meetings. Analyses failed to demonstrate significant
improvements in health-related quality of life in the peer
discussion condition compared to the control group. Vos et al.
[69] found similar results. In their study, 69 breast cancer
patients were randomly allocated to one of three 12-week
conditions: group psychotherapy, support group or control.
There were no group differences on psychosocial adjustment as
measured by three validated instruments. Women who
participated in the peer-support condition perceived more
social support at the end of the program compared to controls.
The sample size used in this study was relatively small so the
lack of statistically significant effects may be due to insufficient
statistical power to detect anything other than medium to large
effects.
The trial reported by Jacobs et al. randomized 34
participants to either a control or an intervention group [68].
The intervention group consisted of eight weekly meetings
focused on the provision of emotional support between
participants. An oncologist, psychologist and social worker
attended the group in non-directive roles. There were no
significant differences between intervention and control groups
on measures of depression, anxiety, interpersonal problems,
anger, and life satisfaction. Although the trial was rated as good
quality, it was limited to some degree. First, emotional
functioning was only measured at the conclusion of the
intervention. Second, the validity and reliability of the
measures were not reported. Third, the small sample size
means the study would only have sufficient statistical power to
detect large effects of peer support.
3.4.5. Group Internet
Two papers reported findings from RCTs exploring Internet
support groups [71,72]. Both examined the effectiveness of an
Internet peer-support program for people with breast cancer.
One paper reported pre-intervention and immediate follow-up
measures [71] and the other paper reported pre-intervention,
short-term and medium-term follow-up [72].
Winzelberg et al. [71] randomly allocated 72 participants to
peer-support or control group. The peer-support program was a
professionally facilitated 12-week structured group that
allowed participants to log onto the Internet and post-messages
to other members at any time. Validated measures assessed
depression, post-traumatic stress symptoms, anxiety, perceived
stress, self-efficacy, and adjustment. The study found that, post-
intervention, groups differed significantly on depression,
perceived stress and symptoms of post-traumatic stress,
suggesting that an Internet-based support program may be
effective in reducing psychological distress among the breast
cancer population.
Gustafson et al. [72] examined a 6-month Internet-based
support program where breast cancer patients accessed a
facilitated bulletin board to post-messages and read personal
stories about coping with the cancer experience at any time.
Two hundred and forty-six women were allocated to either the
intervention or control groups. Control group participants
received a booklet about breast cancer. Validated measures of
social support, unmet information needs and quality of life
were used at pre-intervention, 2 and 5 months post-
intervention. Post-intervention, the intervention group had
higher perceived support and greater confidence in involve-
ment in their own health care. No significant differences in
quality of life were found. The authors suggest that the breast
cancer booklet may have helped control participants to
access information comparable to those in the experimental
condition.
3.4.6. Ratings of the program description and research
quality for RCTs
The average program description quality for the 10 papers
was 18.7, with a range of 15–20 out of 30. The average research
quality rating was 11.6 with a range of 10–13 out of 13. Three
papers scored 100% on all items assessed [63,71,72].The
research quality rating did not include an assessment of the
adequacy of the sample size/necessary statistical power to
detect differences between control and intervention groups.
Table 4 shows that 6 of the 8 RCTs had between 15 and 36
people in the intervention and control groups [63–
65,68,69,71]. The statistical power of these studies would
only be sufficient to detect moderate to large intervention
effects. All papers met the requirement for inclusion on a
Cochrane review (see Table 4 ) although the inclusion of the
study by Rudy et al. [58] might be questionable as no pre-
intervention data was reported.
3.5. Summary of program description and research quality
ratings
Table 5 shows the average program description ratings and
research quality ratings for the different study types. For all
study types, program descriptions were on average rated ‘fair’,
while only the research element of RCTs received on average a
‘good’ rating.
4. Discussion and conclusion
4.1. Discussion
This literature review identified five different models of
peer-support delivery: one-on-one face-to-face, one-on-one
telephone, group face-to-face, group telephone, and group
Internet. The majority of the studies involved women with
breast cancer. Most of the research was reported in descriptive
studies, with only eight RCTs identified. Regardless of study
type, the average program description rating was ‘fair’,
indicating that many elements of the design and delivery of the
peer-support programs were not reported. It is important that
adequate information about these aspects of the peer-support
program is provided if researchers and program providers are
to gain an understanding of the intervention and assess its value
for people of different age, gender, ethnicity and type of cancer.
L.M. Hoey et al. / Patient Education and Counseling 70 (2008) 315–337332
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No study compared the relative effectiveness of different
peer-support models. Overall, results from the one group
descriptive papers indicate a high level of participant
satisfaction and some perceived psychosocial benefits
associated with peer support. Of the 26 papers in this group,
few reported on the experiences associated with one-on-one
face-to-face or telephone-based peer-support programs,
suggesting that these models are infrequently investigated in
the literature. In general, these studies suggest that regardless
of the way peer support is delivered, having contact with other
people with cancer assists current cancer patients in practical,
social and emotional ways. However, as these studies
did not include a control group this suggestion is only
tentative. Most of these descriptive papers received ‘fair’ or
‘poor’ quality ratings due to the lack of information provided
about the peers, the people with cancer and the nature of the
program itself.
Of the 10 papers reporting results from 8 RCTs, four found
an increase in perceived social support among the intervention
group [63,65,69,72] and three found improvements on some
psychosocial outcomes either during or post-intervention
[56,64,65]. Improved psychosocial functioning was found for
a one-on-one face-to-face peer-support model [56] and a group
Internet peer-support model [64,65], suggesting that these
models might be most effective in providing peer support for
people with cancer. Three RCTs examined a group face-to-face
peer-support model and found no significant effect of peer
support on health-related quality of life or psychological
distress. While these findings may suggest that this style of peer
support is ineffective, methodological problems, including
small sample sizes, lack of long-term follow-up, and limited
outcome measures, reduce the strength of any conclusions that
can be drawn from these studies. As this model of peer support
is common in the community, well-designed studies with
adequate statistical power and appropriate outcome measures
are needed to determine the effectiveness of these sorts of peer-
support programs.
As indicated above, both RCTs exploring group Internet
programs were associated with improved psychosocial
outcomes. It is not possible to determine whether these
psychosocial benefits are related to the group Internet format
per se or to some other factor. Both programs were
asynchronous in format, i.e., people logged on to read and
post-messages at any time as opposed to a chat-room format
(i.e., real-time discussions). Perhaps such flexibility is
beneficial, enabling people to access support when needed,
rather than waiting until scheduled meeting times like face-to-
face programs. These programs also went for a longer
time-period (from 12 weeks to 6 months) than other peer-
support programs tested in the RCTs. An extended period of
time may be required for people to develop relationships and
build sufficient rapport to enable them to gain psychosocial
benefits from peer support. This suggestion is supported by
findings from a recent review of professionally facilitated
support groups for cancer patients, which also concluded that
groups lasting longer than 6 months were more efficacious
[22].
It has been suggested that peer support can impact positively
on psychological adaptation to a cancer diagnosis and
treatment, either directly (by decreasing feelings of isolation,
encouraging health behaviours and promoting positive psy-
chological states [21]), or by helping patients to reframe
appraisals of their situations and improve coping responses.
One of the findings of this review is that few studies were
designed to test elements of these models simultaneously.
Rather, many studies drew on both models and assessed coping,
quality of life, health-related quality of life and negative mood
states, resulting in a wide range of outcome measures being
used in this research. In general, the RCTs did not find
significant effects from participation in peer-support programs
on quality of life and coping. This may be a result of the
methodological problems noted above; however, it might also
suggest that these outcome measures are not appropriate for
assessing the effectiveness of peer support. The studies that
assessed more immediate outcomes such as availability of
social support reported a difference in this outcome measure
between intervention and control groups. Few studies evaluated
the success of peer support in terms of reduced isolation,
increased sense of hope and shared experiences: the outcomes
qualitative research has shown that patients involved in peer-
support programs most commonly value and experience [73].
Gottlieb and Wachala [22] noted a similar discrepancy in the
outcome measures used to assess the effect of support groups.
They suggest that research in this area needs to evaluate support
groups in terms of outcomes that match the aims of the
intervention and the experiences of the participants and then
determine whether these outcomes are related to change in
clinically relevant endpoints or outcomes relating to quality of
life or psychological adjustment. Our review leads us to believe
that this conclusion is true for the peer-support literature in
general.
Finally, in trials reviewed in this paper, people were
primarily recruited through hospitals and specialists, and
eligibility was based primarily on demographic and disease-
based status; no RCTs screened for patients’ psychosocial
adjustment or motivation to seek support prior to their program
participation. Recruiting people with low levels of psycholo-
gical distress or who are not open to receiving support may limit
the potential psychosocial improvements and impact on
treatment effect sizes. It has been argued that when
psychosocial interventions are delivered to those most in need,
the positive impact of the intervention is more evident [74].
Further research addressing these recruitment considerations is
warranted.
Throughout this systematic review of the literature strict
procedures were adhered to. Confidence in quality ratings is
reflected by high inter-rater reliabilities. As is the case with
most literature reviews, however, it is possible that some
relevant papers were not identified. We did our best to
minimize this possibility by spending considerable time
planning search terms and liaising with others in the field.
Every possible effort was made to locate all papers that were
identified through the library, Internet and by contacting
authors directly.
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4.2. Conclusion
One important finding from this review is that very little
research has specifically explored the effectiveness of peer-
support programs in improving psychological outcomes for
people affected by cancer other than those with breast cancer,
and it may not be appropriate to generalize these findings to
other cancer populations. It is possible that peer-support
interventions are less likely to impact the adjustment and
quality of life of breast cancer patients as there is, relatively, an
abundance of support (peer and professional) available for this
particular cohort. Perhaps new and innovative peer-support
programs would be beneficial for other groups of cancer
patients, particularly those for whom there may not be a great
deal of support available, for instance people with lung or bowel
cancer. Few research studies have explored the impact of peer-
support programs on volunteers providing support. Given the
potential vulnerability of peers who have a history of cancer
themselves, it is important to monitor the positive and negative
effects on their psychosocial status [30].
Some of the methodological limitations of studies reviewed
here, such as small sample sizes, lack of clear measures
assessing outcomes relevant to the aims of the intervention and
lack of long-term follow-up measurements, compromise
confidence in the findings. RCTs with sufficient statistical
power to determine small to moderate effect sizes are
particularly lacking in this area. We acknowledge that
psychosocial interventions such as peer-support programs are
often generated in the community or by organisations that
might lack the financial and/or academic ability to conduct an
RCT. However, given the limited level I evidence for the
efficacy of peer-support programs, further research is needed to
determine whether peer support actually assists cancer patients
in adjusting to their diagnosis. As a population-based approach
for these trials may not be appropriate, selecting participants
with unmet support needs and comparing different models of
peer support may provide useful information. In addition, it is
essential that future studies consider the effect size they expect
from the intervention and conduct formal power calculation to
ensure sufficient statistical power to detect this effect.
4.3. Practice implications
Currently, only tentative recommendations can be made
regarding models of peer support that might be recommended
for cancer patients. This review suggests that one-on-one face-
to-face and group Internet peer-support programs should be
given priority when considering ways to offer peer support.
Nevertheless, the other models discussed in this review (one-
on-one telephone and group face-to-face) should not be
dismissed until further research is conducted amongst a wide
range of cancer populations.
Disclosure statement
I confirm that all patient/personal identifiers have been
removed or disguised so the patient/person(s) described are not
identifiable and cannot be identified through the details of the
story.
Acknowledgements
This research was supported by the Department of Health
and Ageing, Commonwealth of Australia, administered
through Cancer Australia. We acknowledge the assistance of
Joanna Tilkeridis in the planning of this research and Michelle
Macvean for her advice on the systematic review processes.
Appendix A. Quality rating checklist
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L.M. Hoey et al. / Patient Education and Counseling 70 (2008) 315–337 335
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