Purpose: Nurse navigators and other nurses working with cancer survivors often lead patient and family support groups. An important component of a successful group is group climate, the relationships formed among group members as they interact with each other. We do not know how individual attributes affect group cohesion, an important therapeutic factor in group interventions. The purpose of this secondary analysis was to determine the relationships of anxiety, social desirability, and demographics with group cohesion within a group intervention for African American breast cancer survivors.
Methods: We used univariate linear regression to identify factors associated with group cohesion.
Results: Social desirability was significantly associated with group cohesion at the second time point (P = .033).
Conclusion: We believe that social desirability may have influenced women to report higher levels of cohesion. Group leaders should compare the participants’ perception of group cohesion with the participants’ level of social desirability.
Breast cancer is the most common cancer among African American women in the United States.1 The incidence rate among African American women is 124.3 per 100,000.2 More than 30,700 African American women are diagnosed with breast cancer annually.1 African American women have the highest breast cancer mortality rate.2 Every year, more than 6300 African American women die of breast cancer in the United States.1
Culturally sensitive interventions for African Americans with breast cancer are critically important to promote quality of life and improve survivorship.3 Group interventions, in particular, are useful in increasing social connection,4 providing health information,5 and improving mood,6 thereby improving quality of life and survivorship.7 Given barriers such as long travel time, lack of public transportation, and life in a rural setting, group interventions for African American women with breast cancer must be accessible.8,9
Nurse navigators are in a prime position to facilitate support groups for African American women, identify needs that might be met through a support group, help patients identify support groups in the community, and lead groups.10,11 Since nurse navigators are often the first point of contact for patients, they can educate patients about the benefits of group interventions.12
We created a culturally sensitive therapeutic group intervention by teleconference delivered by telephone for African American women with breast cancer. We reported on the structure and outcome of this intervention previously,4,13-18 but we did not explore the dynamics of group processes. In this paper, we report on the results of our evaluation of group cohesion within the therapeutic groups established for the intervention.
Group cohesion is one critical element in effective group psychosocial interventions19 and is part of the perceived social environment of individuals in a group setting.20 Notably, Yalom21 identified 11 therapeutic factors that are present within groups. Of the 11 factors, group cohesion is defined as the bond among members and sense of connection and belonging to the group.21,22 Cohesion is considered to be a vehicle for change within group interventions.21
Whereas researchers traditionally focused on the within-person processes, or within individuals, in a group setting,23 the relationship between members, known as between-person processes, is not fully explicated in the literature. These differences between members, or individual characteristics such as mood and depression, can affect group interventions.24,25 In particular, we posit group members’ individual anxiety may be associated with group cohesion. Additionally, personality traits such as social desirability can influence how participants respond.26,27 Social desirability is the tendency for individuals to depict themselves in culturally appropriate ways in a given situation.26 We speculate that an individual’s desire to be portrayed favorably within the group may affect the responses on an instrument measuring group cohesion. And last, we hypothesize that demographics such as age, marital status, education, and income influence group cohesion. Differences in these factors may affect perception of group cohesion.28-31
There is a lack of evidence supporting the relationships among anxiety, social desirability, and demographic factors in the perception of group cohesion for African American women with breast cancer participating in a therapeutic group intervention by teleconference delivered by telephone. Furthermore, there is a scarcity of evidence examining how these characteristics affect group cohesion at different time points over the course of the group intervention. Thus, the purpose of this analysis is to determine how individual characteristics affect perceptions of group cohesion over time. Specifically, we wanted to determine the relationships between the characteristics of social desirability, anxiety, and demographics with group cohesion examined at 2 time points within a group intervention.
This descriptive study determined if anxiety, social desirability, or demographic factors were associated with group cohesion. We used secondary data from a larger research study,4 which tested the effectiveness of a therapeutic group intervention by teleconference delivered by telephone for African American women with breast cancer. Further Institutional Review Board approval was granted for post hoc analysis.
We wanted data from 2 time points to measure the change of the group environment within the group. We chose to examine the first session as a baseline of the group experience. The seventh session was the second time point to represent the maturation of the group, referred to as the working stage.32 During the working stage, group members trust each other and share their difficult experiences. As group members identify with each other in this working stage, they are willing to learn and accept coping strategies that others use. We believe group members would have established trust and freely exchanged stories about their cancer experience by the seventh session. Thus, we chose to compare the results from the seventh session with the first session to demonstrate changes that may have occurred within the group.
The original study was conducted throughout 1 Southern state where the majority of the participants lived within 75 miles of the study site. Physicians and other healthcare providers assisted in recruitment. The eligibility criteria for African American women included a diagnosis of invasive ductal breast cancer and history of a lumpectomy within the past 6 months upon enrollment. The women also needed to speak English.4 The participants signed informed consents. One hundred eighty-five African American women with breast cancer enrolled in the original study, with 92 women in the intervention and 93 women in the control group. The control group received standard, usual care and did not receive the group teleconference via telephone intervention.
The original intervention was a randomized controlled trial that used teleconference via telephone to deliver a therapeutic group intervention for African American women with breast cancer.4 The intervention arm consisted of 8 therapeutic sessions followed by 2 booster sessions, with each session lasting approximately 90 minutes. The first 10 minutes of the sessions included an introduction, followed by 30 minutes of presentations guided by the group leaders. Following the presentations, the participants discussed the session topic for 45 minutes, with 5 minutes of closure.
Description of the Intervention
The components of the intervention consisted of 3 main parts: personal storytelling, sessions guided by group leaders, and individual reflections on various coping stories.4 The topics for the teleconference sessions ranged from information about: 1) methods of coping; 2) feelings, fears, and myths; 3) stress management; 4) family relationships; 5) treatment; 6) intimacy and self-image; 7) recurrence; and 8) social networks.14 Each session offered valuable tools and techniques for women with breast cancer. For example, participants learned about the importance of relaxation, and at the end of the session the group leaders guided the women through a focused breathing exercise. The coping stories were presented as vignettes that illustrated less effective coping and positive coping strategies. The topics of the coping stories consisted of diagnosis, depression, doctor-patient relationships, family, treatment, sexuality, future planning, returning to normal, and personal stories.14 The group leaders encouraged discussion after the review of the stories.14 The race concordant group leaders were trained to be consistent throughout each session to maintain intervention fidelity.
We used Yalom’s goals for short-term inpatient therapy to guide the teleconference intervention21 because the structure of the intervention was limited to 8 therapeutic sessions. Yalom’s original theoretical work was with long-term weekly group therapy participants. Although the teleconference intervention was not inpatient, our pilot study work revealed participants could become more intimate over the phone than in person.22 In fact, participants said they felt more at ease meeting anonymously and described feeling a deeper level of intimacy within the teleconference group setting.22 Because participants could not respond to visual cues common within traditional inpatient group settings, the group leaders were trained to be more attentive to tone of voice and inflection.33 The group leaders encouraged participants who were less involved in the discussion by repeating names and checking in with silent members.14
In the original study, baseline data were gathered prior to initiation of the first group session and included the health data form, Profile of Mood States – Short Form (POMS-SF), and the Marlowe-Crowne Social Desirability Scale (MC-SDS). Group cohesion was assessed at the end of the first session and seventh session. To increase responses to the instrument, group leaders read the instrument at the end of the session and encouraged participants to complete it as the items were read to them. Each participant was provided with a self-addressed stamped envelope to facilitate return. We had a good return rate of 58.4% in comparison with some studies that reported only a 10% return on mailed surveys.34
For this particular analysis, we focused only on the intervention arm of the trial. Furthermore, we examined participant responses from 2 time points during the first and seventh group therapy sessions. We excluded participants who had missing data. Thus, the final dataset for this analysis included 38 participants from the intervention arm.
For this secondary analysis, we used the data gathered from a health data form, the Group Climate Questionnaire – Short Form (GCQ-S), the POMS-SF at baseline, and the MC-SDS at baseline. These instruments from the original study were chosen based on their use in similar populations with cancer and low participant burden regarding the number of items.4
Health Data Form
We used a standard health data form to obtain demographic information and a health history. For the purposes of this analysis, we only focused on information pertaining to age, partner status, income, and education. The questions on the health data form included 25 items. Answer selections ranged from “fill in the blank” to “select all that apply.”4
We used the GCQ-S to measure our dependent variable of cohesion, a highly critical therapeutic factor arising from members interacting and forming close bonds with each other.21,35 We operationalized cohesion as the score from the engagement subscale. For this study, α = 0.64. The GCQ-S consists of 12 items on a Likert scale. The responses range from 0 meaning “not at all” to 6 being “extremely.” The score is determined by calculating the raw mean score of 5 items measuring cohesion. The possible ranges of scores include 0 and 6 as the theoretical minimum and maximum, respectively.
We used the POMS-SF to identify individual mood. For the purposes of this analysis, the tension-anxiety subscale was used to approximate the participants’ level of anxiety.36 The Cronbach α for the tension-anxiety subscale for this sample was 0.83. The responses range from 0 meaning “not at all” to 4 being “extremely.” The greater numerical score reflects increased levels of anxiety and tension. Five questions pertain to the tension-anxiety subscale. Scores are calculated by multiplying each response by the designated weight (+1 or –1) and then summing them together. The theoretical maximum and minimum scores are 20 and 0, respectively.
The third scale, the MC-SDS, is used to measure an individual’s need for acceptance.37 Researchers use the scale to validate against participants responding with socially desirable answers.38 Burris and colleagues39 reported moderate reliability for this scale; the sample was not inclusive of only African Americans. Fernander and colleagues40 also examined social desirability using a diverse sample. For this study, the Kuder-Richardson 20 test revealed the subscale was α = 0.196. The 10-item scale consists of true/false statements. The participants’ responses are compared with the scoring guide. Items are assigned 1 point for every concordant pair, with 10 being fully matched and 0 with responses having no match. The theoretical range of the scores is 0 to 10.
We performed all analyses using SPSS Statistics 23. Descriptive statistics of frequencies and means were calculated initially to further understand the sample population. Due to the small sample size, we chose to run univariate models with each demographic factor or psychometric measure as the independent variable in the model and cohesion score from session 1 and session 7 as the dependent variables.
Participant demographics of the study sample are found in Table 1. Participants, on average, were 55 years of age, and the majority were partnered, had an income between $20,000 and $39,000 per year, and were high school graduates. The participants’ tension-anxiety score was low at 4.47. The participants reported a high level of social desirability at baseline (x̄ = 7.13) and moderately high cohesion (x̄ = 4.16) after the first session. By the seventh session, cohesion slightly increased (x̄ = 4.23). Additional descriptive statistics for psychosocial measures are shown in Table 2.
Univariate modeling results for the demographic and psychosocial independent variables using either session 1 or session 7 cohesion as the dependent variable are presented in Table 3. After running univariate models with the independent variables, the results showed that social desirability was significantly associated with cohesion at the seventh session (P = .033). A 1-unit increase in the social desirability score resulted in a significant 0.183 increase in the group cohesion score at session 7. Interestingly, social desirability was not significantly associated with group cohesion for the first session. Tension-anxiety was not significantly associated with group cohesion during either session. Additionally, the hypothesized demographics such as age, marital status, education, and income did not influence group cohesion.
In this post hoc analysis of a randomized controlled trial using therapeutic group teleconference delivered by telephone for African American women with breast cancer, social desirability is associated with group cohesion. However, this association is only significant during the seventh session; social desirability is not significant at the first session.
We suspect the variability between the sessions is a result of the group process. During the first session, participants have not yet formed bonds with the group members, and consequently, individuals retain their personal culture. As the group progresses, the individual develops stronger ties to the group. At this point, the individual becomes influenced by the group, which may change the individual’s perceptions about her situation, stressors, and coping strategies used. Despite the narrow increase of cohesion between the first and seventh session, the change represents the shift of an individual’s connection and perception of her group. Essentially, the group members’ individuality melded into the group’s culture, creating a unique group environment. This change in individuality reflects the significance with social desirability only at the seventh session.
Individual anxiety is known to impact group climate, particularly to motivate group members to explore common concerns and coping strategies.21 Thus, it is surprising that the group participants’ tension-anxiety was not related to group cohesion.
Given our results, we believe that nurses leading support groups should be aware of the influence of social desirability on perceptions of group cohesion. Group leaders should monitor group cohesion throughout the group experience as this is one quality measure for a support group. Being aware of the potential effect of social desirability on group climate helps prevent negative group processes and helps identify when a leadership strategy is needed to help the group become more cohesive. For example, the group leader should check in with the group and ask members to evaluate how close they feel to each other. Group leaders may need to help groups understand that avoiding difficult topics leads to greater cohesion and more support from group members, especially if discrepancies between what group members state about cohesion is different from what the leader observes. This is especially true if the group members seem resistant to self-disclosure.
In a research study that uses a support group intervention, the researchers should also examine group cohesion and social desirability of group members. Since group cohesion is one measure of intervention fidelity (are the participants receiving the intervention as it was intended to be delivered?), the research team may need to address this issue and identify strategies to circumvent the strength hypothesis in African American participants. If the group leaders determine that women may have greater social desirability traits, then group leaders will need to carefully monitor group cohesion to assure that therapeutic factors emerge during discussions. Group leaders will need to especially address concerns over topics that are difficult to discuss, such as sexuality.32
Despite the limitation that only 38 of the 92 women in the total sample returned group climate surveys at both session 1 and session 7, this study is unique. Whereas social desirability has been explored in cancer screenings,41 limited studies exist examining social desirability in interventions for cancer survivors. Furthermore, our study was the first to quantify the effect of social desirability on group cohesion. Upon initial review, this study may be the first to examine social desirability and group cohesion among African American women with breast cancer.
In conclusion, we found evidence for the influence of social desirability on cohesion in group interventions for African American women with breast cancer. We anticipate using this study as a launching point for researchers to study social desirability and interventions for cancer survivorship.
This article was supported by funding from the National Institutes of Health, National Cancer Institute grant R01CA107305.
- American Cancer Society. Cancer Facts & Figures for African Americans 2016-2018. Atlanta, GA: American Cancer Society; 2016.
- DeSantis CE, Fedewa SA, Goding Sauer A, et al. Breast cancer statistics, 2015: convergence of incidence rates between black and white women. CA Cancer J Clin. 2016;66:31-42.
- Kreuter MW, Lukwago SN, Bucholtz RD, et al. Achieving cultural appropriateness in health promotion programs: targeted and tailored approaches. Health Educ Behav. 2003;30:133-146.
- Heiney SP, Millon Underwood S, Tavakoli A, et al. Randomized trial of therapeutic group by teleconference: African American women with breast cancer. Cancer. 2012;118:3822-3832.
- Williams-Brown S, Baldwin DM, Bakos A. Storytelling as a method to teach African American women breast health information. J Cancer Ed. 2002;17:227-230.
- Classen C, Butler LD, Koopman C, et al. Supportive-expressive group therapy and distress in patients with metastatic breast cancer: a randomized clinical intervention trial. Arch Gen Psychiatry. 2011;58:494-501.
- Friedman LC, Kalidas M, Elledge R, et al. Optimism, social support and psychosocial functioning among women with breast cancer. Psychooncology. 2006;15:595-603.
- Adams SA, Smith ER, Hardin J, et al. Racial differences in follow-up of abnormal mammography findings among economically disadvantaged women. Cancer. 2009;115:5788-5797.
- Meneses K, Azuero A, Su X, et al. Predictors of attrition among rural breast cancer survivors. Res Nurs Health. 2014;37:21-31.
- McMullen L. Oncology nurse navigators and the continuum of cancer care. Semin Oncol Nurs. 2013;29:105-117.
- Case MA. Oncology nurse navigator. Clin J Oncol Nurs. 2011;15:33-40.
- Till JE. Evaluation of support groups for women with breast cancer: importance of the navigator role. Health Qual Life Outcomes. 2003;1:16.
- Heiney SP, Tavaloki A, Millon Underwood S, et al. Social connection in African-American women with breast cancer. J Natl Black Nurses Assoc. 2013;24:1-7.
- Heiney SP, Adams SA, Wells LM, et al. Participant evaluation of teleconference support for African American women with breast cancer. Cancer Nurs. 2012;35:E24-E30.
- Heiney SP, Gullatte M, Hayne PD, et al. Fatalism revisited: further psychometric testing across two studies. J Relig Health. 2016;55:1472-1481.
- Heiney SP, Reavis K, Tavakoli AS, et al. The impact of STORY on depression and fatigue in African-American women with breast cancer. J Natl Black Nurses Assoc. 2015;26:1-7.
- Heiney SP, Adams SA, Wells LM, et al. Evaluation of conceptual framework for recruitment of African American patients with breast cancer. Oncol Nurs Forum. 2010;37:E160-E167.
- Heiney SP, Hazlett LJ, Weinrich SP, et al. Antecedents and mediators of community connection in African American women with breast cancer. Res Theory Nurs Pract. 2011;25:252-270.
- Burlingame GM, McClendon DT, Alonso J. Cohesion in group therapy. Psychotherapy. 2011;48:34-42.
- Kivlighan DM, Paquin JD, Hsu YK. Is it the unexpected experience that keeps them coming back? Group climate and session attendance examined between groups, between members, and between sessions. J Couns Psychol. 2014;61:325-332.
- Yalom ID. Inpatient Group Psychotherapy. New York, NY: Basic Books; 1983.
- Heiney SP, McWayne J, Walker S, et al. Evaluation of a therapeutic group by telephone for women with breast cancer. J Psychosocial Oncol. 2003;21:63-80.
- Curran PJ, Bauer DJ. The disaggregation of within-person and between-person effects in longitudinal models of change. Annu Rev Psychol. 2011;62:583-619.
- Oei TP, Browne A. Components of group processes: have they contributed to the outcome of mood and anxiety disorder patients in a group Cognitive-Behaviour Therapy program? Am J Psychother. 2006;60:53-70.
- Taube-Schiff M, Suvak MK, Antony MM, et al. Group cohesion in cognitive-behavioral group therapy for social phobia. Behav Res Ther. 2007;45:687-698.
- Adams SA, Matthews CE, Ebbeling CB, et al. The effect of social desirability and social approval on self-reports of physical activity. Am J Epidemiol. 2005;161:389-398.
- Hébert JR, Hurley TG, Peterson KE, et al. Social desirability trait influences on self-reported dietary measures among diverse participants in a multicenter multiple risk factor trial. J Nutr. 2008;138:226S-234S.
- Dunlop WL, Beauchamp MR. The relationship between intra-group age similarity and exercise adherence. Am J Prev Med. 2012;42:53-55.
- Kawachi I, Kennedy BP. Health and social cohesion: why care about income inequality? BMJ. 1997;314:1037-1040.
- Lerman C, Schwartz MD, Miller SM, et al. A randomized trial of breast cancer risk counseling: interacting effects of counseling, educational level, and coping style. Health Psychol. 1996;15:75-83.
- Goodwin PJ, Leszcz M, Ennis M, et al. The effect of group psychosocial support on survival in metastatic breast cancer. N Engl J Med. 2001;345:1719-1726.
- Heiney SP, Wells LM. Strategies for organizing and maintaining successful support groups. Oncol Nurs Forum. 1989;16:803-809.
- Heiney SP, Darr-Hope H, Howell C. The supportive survivors. Reflections. 1999;25:14-16.
- Sinclair M, O’Toole J, Malawaraarachchi M, et al. Comparison of response rates and cost-effectiveness for a community-based survey: postal, internet and telephone modes with generic or personalised recruitment approaches. BMC Med Res Methodol. 2012;12:132.
- MacKenzie KR. The clinical application of a group climate measure. In: Dies RR, MacKenzie KR, eds. Advances in Group Psychotherapy: Integrating Research and Practice. New York, NY: International Universities Press; 1983:159-170.
- McNair DM, Lorr M, Droppleman LF. Manual for the Profile of Mood States. San Diego, CA: Educational and Industrial Testing Service; 1992.
- Marlowe D, Crowne DP. Social desirability and response to perceived situational demands. J Consult Psychol. 1961;25:109-115.
- Leite WL, Beretvas SN. Validation of scores on the Marlowe-Crowne Social Desirability Scale and the Balanced Inventory of Desirable Responding. Educational and Psychological Measurement. 2005;65(1):140-154.
- Burris JE, Johnson TP, O’Rourke DP. Validating Self-Reports of Socially Desirable Behaviors. Nashville, TN: American Association for Public Opinion Research; 2003.
- Fernander AF, Durán RE, Saab PG, et al. Assessing the reliability and validity of the John Henry Active Coping Scale in an urban sample of African Americans and white Americans. Ethn Health. 2003;8:147-161.
- Carter-Harris L, Hermann CP, Schreiber J, et al. Lung cancer stigma predicts timing of medical help-seeking behavior. Oncol Nurs Forum. 2014;41:E203-E210.