Running head: AN EVALUATION OF THE EFFECTS OF SOCIAL

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Effect of Social Support on Health Empowerment and Perceived Well-Being in Adults Impacted
By Cancer: A Program Evaluation.
Suzanne O’Rourke BSN, RN
Arizona State University

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Abstract
Background: Cancer impacts the lives of millions of patients, families and caregivers annually
leading to chronic stress, a sense of powerlessness, and decreased autonomy. Social support may
improve health empowerment and lead to increased perception of well-being.
Purpose: The purpose of this project was to evaluate the effectiveness of social support provided
by a cancer support agency on health empowerment and perceived well-being in adults impacted
by cancer.
Conceptual Framework: The Health Empowerment Theory maintains that perceived wellbeing is the desired outcome; mediated by health empowerment through social support, personal
growth, and purposeful participation in active goal attainment.
Methods: Twelve adults impacted by cancer agreed to complete online questionnaires at
baseline and at 12 weeks after beginning participation in social support programs provided by a
cancer support agency. Instruments included: Patient Empowerment Scale, The Short WarwickEdinburgh Mental Well-Being Scale (SWEMWBS), and The Office of National Statistics (ONS)
Subjective Well-Being Questions.
Results: Four participants completed pre and post surveys. An increase was seen in
empowerment scores (pre M = 1.78, SD = 0.35 and post M = 3.05, SD = 0.42). There was no
increase in perceived well-being: SWEMWBS pre (M= 3.71, SD= 0.76), post (M= 3.57, SD=
0.65); ONS pre (M= 7.69, SD= 1.36), post (M= 6.59, SD= 1.52).
Implications: The data showed an increase in health empowerment scores after utilizing social
support programs, lending support to the agency’s support strategies. It is recommended that the
measures be included in surveys routinely conducted by the agency to continue to assess the
impact of programming on health empowerment, and perceived well-being.

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Keywords: empowerment, well-being, cancer, social support, intervention
Effect of Social Support on Health Empowerment and Perceived Well-Being in Adults Impacted
By Cancer: A Program Evaluation
The diagnosis of cancer immediately elicits a myriad of negative emotions and fear. Both
patients and loved ones, have difficulty processing and coping with this life-changing event.
Community social support agencies provide assistance to individuals who have been impacted by
cancer. These agencies provide tools and opportunities to process the emotions of a cancer
diagnosis through positive social support interventions, which may improve health
empowerment and ultimately increase the perception of well-being.
Background and Significance
In the United States the lifetime average of developing cancer is 40%. Cancer is the second
leading cause of death with approximately 1.6 million newly diagnosed, and half a million deaths
estimated for 2015 (Siegel, Miller, & Jemal, 2015). Historically, the diagnosis of cancer was
viewed as a terminal illness invoking fear and uncertainty. This perception is rapidly changing as
researchers are developing new treatments making it possible for patients to live longer than ever
before; a cancer diagnosis is now often treated as a chronic illness (Siegel et al., 2015).
According to the National Cancer Institute: Surveillance, Epidemiology, and End Results
Program [NCI; SEER] (2015), between 1991 and 2011 the overall cancer death rate due to
cancer decreased by 22% and the average five-year survival rate increased by 20% for all types
of cancer. However, patients are often left with chronic physical and psychological ramifications
of their disease (Regan et al., 2014).
Cancer treatments such as chemotherapy, radiation, and surgery have side effects
including pain, fatigue, nausea, gastrointestinal upset, and hair loss. Depending on the type of

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cancer, there may be higher rates of depression and anxiety, disfigurement, or sexual
dysfunction, which can lead to altered body image, decreased partner intimacy and increased
depression (Sengual et al., 2014; Yilmaz et al., 2015; Hughes et al., 2015, Paterson et al., 2013).
The diagnosis of cancer impacts patients and the families physically, emotionally,
economically, and socially (Sengul et al., 2014). Much of their time is spent at doctor visits,
outpatient treatment centers, and hospitals. Social networks that were previously embedded into
one’s life continue but are often disrupted. However, research demonstrates that positive social
support and perceived social support can directly impact both mental and physical health
(Mosher, 2013) (McCorkle, 2011).
The health risks of increased stress on the biological systems can be severe. Hughes et al.
(2014) studied women with breast cancer and suggested a connection between lowered social
support at the beginning of cancer treatment and higher levels of pain and depressive symptoms
as well as IL-6 (a pro-inflammatory cytokine) inflammation at the six month post treatment
compared to those who reported higher levels of social support at the beginning of their
treatment. In a recent meta-analysis (Holt-Lunstad, Smith, Baker, Harris, & Stephenson, 2015)
examining mortality outcomes and social support, researchers found that social isolation,
loneliness, and living alone is associated with a 25-30% increase in mortality. Other studies
reveal the negative impact that stress has on the overall survival rates of cancer patients (Reuter,
Gupta, Chatervedi & Aggarwal, 2010).
Cancer affects not just the individual, but the family as well. Loved ones provide support
to the patient as well as dealing with their own emotions about an uncertain prognosis. And as
time goes on, the patient’s physical needs may increase, leaving the family to cope with
increasing challenges. This may not be an overwhelming burden for everyone, but often,

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caregivers are aging spouses or other family members who are not able to continue the
demanding physical care required by declining patients. Caring for an individual with cancer is
physically and psychologically challenging and takes a toll on a caregiver’s health as well
(Hayman et al., 2001). Romito, Goldzweig, Cormio, Hagedoorn, and Anderson (2013) suggest
the need for better caregiver support and discharge education plans similar to that of stroke and
cardiac patients, in hopes to minimize personal financial loss and decrease the additional burden
on the healthcare system as well as the public welfare system.
Social Support
While the definition of support varies widely, it generally falls into one of three
categories: emotional support, physical cares and support, or educational/informational support
during a difficult time (Holt-Lunstad & Uchino, 2015). The effect of social support on one’s
health is clearly documented. In a landmark social sciences study, House, Umberson, and Landis
(1988) proposed that social support, relational demands, and social regulation are the processes
that are produced by the social structures of community togetherness and unions; whereby these
processes have a direct positive or negative effect on an individual’s health. A recent study by
Puetz, Morley, and Herring (2013) describes the benefits of creative art therapies by cancer
patients both in the hospital and ambulatory settings. The study reports a significant reduction in
pain, anxiety, and depression with a related increase in quality of life and overall-well-being.
Health Empowerment
Health empowerment is one aspect of the larger picture of overall well-being. It is the
individual’s belief that they have the innate power and resources to accomplish goals and
overcome life events (Diener & Biswas-Diener, 2005) as well as confidence and self-esteem
(Shearer & Reed, 2004). The definition of empowerment is subjective depending on the context

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in which it is used. Brunet et al (2015) defines empowerment as a one’s ability to govern or
regulate the experiences and challenges while maintaining a sense of control over his or her life;
the individual will understand and participate, utilize available resources and take actions that
will reduce anxiety, improve self-management which will improve quality of life and overall
well-being. An individual with cancer may feel a sense of powerlessness, as they are frequently
navigating countless appointments that fill up their calendars, and are constantly given
information that is often beyond their comprehension.
Perceived Well-Being
Perceived well-being is generally recognized as overall harmony and life satisfaction
(Gueldner et al., 2005), or positive interpretations of one’s life, including pleasant feelings,
accomplishments, and life satisfaction (Diener & Biswas-Diener, 2005). It is one’s thoughts and
feelings about their own happiness, and how their life is going (Graham, 2010).
Internal Evidence
A non-profit cancer support agency in a metropolitan area of the southwestern United
States (U.S.) providing social support programs to members of the community experiencing a
cancer diagnosis requested assistance evaluating current social support programming on client
outcomes. Clients currently have cancer, are cancer survivors, or are a loved one or caregiver of
someone with cancer. The agency offers social support in many ways, and is interested in
determining if programs provide a sense of empowerment and overall well-being in participants.
Such information can be utilized to enhance program effectiveness. The agency’s ability to
obtain funding is also impacted by the ability to demonstrate program effectiveness.

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Problem Statement
Cancer is a global concern. It does not discriminate between age, gender, race or ethnicity. It has
an effect on every part of one’s life – physical, emotional, spiritual, and social; which impact a
person’s sense of well-being. Participation in formal and informal social support activities may
increase a sense of health empowerment improving perceived well-being and health status.
PICOT
This inquiry has led to the clinically relevant question: In adults with cancer and/or their
caregivers (P), how does the use of social support activities and services (I), compared to not
using social support (C), affect empowerment and overall well-being (O) over 12 weeks (T)?
Search Strategy
Literature searches included EBSCO host, ProQuest PsychInfo, and NCBI Pubmed.
Keywords/Boolean phrases used were: cancer and/OR empowerment OR well-being, social
support intervention, and not diabetes. Limiters included year (no earlier than 2005), full text,
English language, and peer reviewed. A total of forty-two abstracts were reviewed, and a total of
six articles were selected.
Evidence Synthesis
A total of six studies were chosen for review. The rapid critical appraisal approach was
utilized to evaluate the evidence. The studies chosen are of varying levels of evidence from
Level II to Level VI, and also vary greatly in the designs and methods used. Of the six studies
reviewed two were longitudinal – one of which is a 5-year random controlled trial, two mixedmethods, and two systematic reviews. Of the studies reviewed, the majority are qualitative with
Levels V or VI and one Level II. All were studies that focused on the influence of social support
interventions or perceived support on health empowerment and perceived well-being outcomes.

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Direct correlations included an improvement in well-being after social support and group
participation, as well as community based programs enable and empower participants (Hoey,
2008); Hughes, (2014), McCorkle, (2011), Paterson, (2013), Puetz, (2013), Stang, (2009),
Ussher, (2005). Most studies were centered on the cancer patient, with others addressing the
caregivers (Haymen, 2001; Mosher, 2013; Regan, 2013; Romito, 2013). Overall, all studies
reviewed displayed a broad degree of sample demographics including gender, age (>18 years),
socioeconomic status, and types of cancer.
There are several factors to be considered when evaluating research in this population.
First, there can be a high rate of attrition due to the nature of the disease. Although cancer is a
global concern, cultural factors may influence results. The majority of the studies were funded by
federal or national grants, or no funding was declared. Potential areas for bias were researcher
affiliation with a major health institution, samples of convenience, and low level and limited
evidence.
However, the overarching theme of these articles was that social support interventions do
provide a sense of empowerment, togetherness, and hope, increasing overall well-being during
times of stress.
Purpose Statement
The purpose of this project was to evaluate the effectiveness of social support provided
by a cancer support agency on health empowerment and perceived well-being in adults impacted
by cancer.
Evidence Based Practice Model
Rosswurm and Larrabee’s Model for Evidence-Based Practice Change (1999) was used
to guide this project. There are six steps to the model, but this project focused on the first three

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steps – 1.) Assess the need for change, 2.) Link the problem with interventions and outcomes,
3.) Synthesize the best evidence (Rosswurm & Larrabee, 1999). The need for change is based on
the support community’s request for program evaluation. The problem is defined as an
increasing number of individuals experiencing a cancer diagnosis who may have physical,
emotional, and/or psychosocial unmet needs that may benefit from social interventions offered
through the organization which evidence shows can increase a sense of empowerment and
overall well-being. The fourth step in the Rosswurm and Larabee Model (1999) is to design a
change in practice. After internal evidence is collected and analyzed, the information can be used
to inform future programming.
Theoretical Model
The Health Empowerment Theory (Shearer, 2009) provided the conceptual framework
for this project. According to Shearer (2009) health empowerment stems from a fusion of
resources, both personal and social-contextual that may include self-capacity, support from
social services and networks available to the individual. It is a deliberate course of action an
individual takes in order to change oneself and their environment, to recognize patterns, and
draw strength from inner resources for their well-being and goal attainment (Shearer, 2009).
Health empowerment is defined as “a dynamic health process that emphasizes ‘purposefully
participating in a process of changing oneself and one’s environment, recognizing patterns, and
engaging inner resources for well-being’”. Health empowerment is realized through personal
growth, self-acceptance, purpose and social support; these constructs guide the individuals’
awareness, choices, and intentional actions, which lead to perceived well-being (Shearer, 2009).
The desired health outcome is ultimately perceived well-being. Health Empowerment
Interventions consist of personal resources such as self-capacity building to acknowledge and

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reinforce personal strengths and self-advocacy, and social contextual resources to reinforce and
promote social connections, resources, and promote problem-solving skills. Health
empowerment is conceptualized as a mediator through, which through personal growth, selfacceptance, social support, utilization of social services, and defining one’s purpose in life is
achieved.
Methods
Ethics
IRB approval was applied for and exemption was granted on September 15, 2016. CITI
training for human participants were completed. Agency approval and a site letter were obtained.
Setting
The project was conducted at a non-profit community cancer support agency located in
the southwest United States. The organization reports serving 1,875 clients in 2014. Clients
consist of individuals of all ages, cancer diagnosis/status, including friends, loved-ones and
caregivers who have also been impacted by a cancer diagnosis.
Participants
Inclusion criteria were: adults over the age of 18 with a current or previous diagnosis of
cancer, or a friend, relative, loved one or caregiver of someone with a cancer diagnosis.
Individuals under the age of 18, unable to consent, and those could not read or write English
were excluded.
Procedures
The student project director presented information about the project at the meetings
using the recruitment script and answered any questions at weekly newcomer meetings. No

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advertisements or flyers were used to recruit participants. The time period for data collection was
September 2016 to March 15, 2017. No compensation was provided to participants.
Once individuals agreed to participate, they received an email that included the consent
letter with a link to the surveys through the student project directors privately held Survey
Monkey platform. Participation in the survey was considered consent. The link was available to
the participant for seven days following notification for both the initial survey and the 12-week
follow-up survey. At twelve-weeks, the participant received a second email with the survey link
for the follow up survey, which also remained open for seven days. Participants generated a
unique, anonymous identifier for both the pre and post intervention surveys, online and paper
versions. Paper surveys were available, however no participants requested the paper version.
Interventions
The community support agency uses five pillars or umbrellas to encompass their support
programs; they include support services, education, healthy lifestyle, social connections and
resource and referral. Clients may join any class or program at no cost to them. This project did
not introduce any new interventions or attempt to manipulate the type or frequency of services
attended by participants.
Outcome Measures
Outcomes were measured by the use of three tools. Health Empowerment was measured
using The Patient Empowerment Scale (PES) (Bulsara, Styles, Ward & Bulsara, 2006). The PES
consist of 15 questions such as ‘I am capable of handling my/my loved ones illness’ measured on
a four-point Likert-scale ranging from ‘strongly agree to strongly disagree’ whereas a higher
score equates to a higher level of empowerment. Psychometric testing was conducted by the
instrument developers demonstrating that the instrument can be used in assessing level of

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empowerment amongst cancer patients (Bulsara, Styles, Ward, & Bulsara 2006). No other
studies were found to report additional validity or reliability although, communication with the
primary developer indicated there is a large prostate cancer study currently in progress in the
United Kingdom using the tool to evaluate health empowerment levels for men.
Participant well-being was measured by multiple short form questionnaires developed by
the Centre for Well-being and The New Economics Foundation for the Office of National
Statistics (ONS), and the Short Warwick- Edinburgh Mental Well-being Scale (SWEMWBS,
2015). The SWEMWBS is seven questions on a five-point Likert-scale which reflect the
individual’s thoughts and feelings using questions such as “I’ve been feeling optimistic about the
future” Stewart-Brown et al., (2011) reports a Cronbach’s α (0.89). Validity has been assessed by
correlating well-being with mindfulness, emotional intelligence and positive affect revealing
weak to strong positive correlations (r = .13 to .61) (Haver, Akerjordet, Caputi, Furunes, &
Magee, 2015).
The ONS questionnaire consists of four questions on a 0-10 point scale, and reflects the
clients’ feelings about life satisfaction, happiness, and anxiety. Diener (2011) reports a Cronbach
∝ (0.8 and 0.96) on a meta-review of the reliability of the subjective well-being measures of life
satisfaction.
Data Collection
Twelve clients agreed to participate, six completed the pre-intervention survey, and four
completed the post-intervention survey at 12-weeks. The data was stored in the private, password
protected account until data extraction into SPSS 24 occurred for analysis.
Results

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Demographic data shows all participants were white, female, 50% were
married/partnered with the other 50% separated or divorced. All participants were over the age
of 31 years; Most of the clients were patients (83%). Three (50%) were newly diagnosed, 66%
were currently undergoing treatment, and 16% were in remission (Table 1). Four participants
completed pre and post surveys. An increase was seen in empowerment scores (pre M = 1.78, SD
= 0.35 and post M = 3.05, SD = 0.42). However, there was no increase in perceived well-being as
measured by the SWEMWBS (pre-intervention scores M= 3.71, SD= 0.76 and post-intervention
scores M= 3.57, SD= 0.65); or the ONS ( pre-intervention scores M= 7.69, SD= 1.36 and postintervention scores M= 6.59, SD= 1.52).
Discussion
In spite of the small sample size, results supported increased health empowerment after
12 weeks of participation in social support activities. Shearer (2009) describes health
empowerment as a precursor to perceived well-being therefore, overtime, there may be an
increase in perceived well-being.
The results of this project align with other research in this field. Ussher & colleagues
(2006) relate utilization of cancer social support groups to an increase in confidence and a sense
of control as it relates to self, cancer, and interactions with others – specifically health care
providers – which increases health empowerment. Stang & Mittelmark (2009) report social
support interventions that focus on intrapersonal, interactional, and behavioral components
increase health empowerment. Additionally, models of peer social support methods were
reviewed by Hoey et al. (2008), which showed that regardless of the method, contact with others
with a shared cancer experience provides psychosocial and emotional benefits leading to an
increased sense of health empowerment.

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Limitations
There were a number of barriers and limitations during this project. There were two newmember meetings in which there were no participants. The project also was conducted over the
Christmas and New Year holidays, which may have contributed to the low participation.
Additionally, this is a vulnerable population in which fatigue is common and placing an
additional burden of completing surveys may lower participation.
Conclusion and Implications
Results of this project lend support to programming conducted by a cancer support
agency in southwestern United States to provide social support to participants impacted by
cancer to promote health empowerment. Although the exact mechanism is not fully understood,
research demonstrates that social support improves health empowerment and perceived wellbeing measures for patients and caregivers experiencing the diagnosis of cancer. Further study is
needed to investigate the specific social support strategies most effective in improving health
empowerment and links to perceived well being.

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AN EVALUATION OF THE EFFECTS OF SOCIAL
Table 1
Demographic Data
Pre-intervention n=6
Gender
Age
Ethnicity
Marital Status
Patient or Caregiver
Treatment Status

Female
Male
By Intervals
Caucasian
Married/Partnered
Divorced/Single
Patient
Caregiver
New Patient
Undergoing Treatment
Remission

20

83%
16%
2 (31-50), 2 (51-69), 2 (70+)
100%
50%
50%
83%
17%
3 – 50%
4 – 66%
1 – 16%