Connectedness to the young adult cancer community and post‐traumatic growth: A young adults with cancer in their prime study

For young adults (YAs) with cancer, connecting with peer cancer survivors can provide a unique sense of community and may enhance post‐traumatic growth (PTG). This study examined the relationship between connectedness to the YA cancer community and PTG among YAs, independent of overall social support.

-1 of 8 https://doi.org/10.1002/pon.6325Each year, approximately 7600 young adults (YAs) aged 20-39 are diagnosed with cancer in Canada. 1,2Although cancer remains a leading cause of death in YAs, survival rates are increasing resulting in a growing population of long-term YA survivors. 1,24][5][6] Despite the difficult experience of cancer, some individuals experience personal growth. 7The positive changes that result from highly challenging life experiences are defined as post-traumatic growth (PTG). 8cording to the model proposed by Tedeshi and Calhoun, 8 PTG results from cognitive processing that occurs during self-disclosure and persistent rumination about a traumatic event.Tedeshi and Calhoun explain that PTG develops as individuals attempt to manage their distress, make sense of their experience, and adapt to their new circumstances.PTG can manifest as an increased appreciation for life, more meaningful interpersonal relationships, a greater sense of personal strength, reorganization of priorities, and a richer existential experience.A 2019 systematic review reported that moderate-to-high PTG is experienced by 52% of individuals following a traumatic life event (including cancer) 9 and is more commonly experienced in younger individuals.Individuals who experience moderate-to-high PTG report lower levels of distress 10 and greater quality of life 11 over time.
Social support is an integral aspect of PTG. 8 Social support directly influences PTG by providing a supportive environment to facilitate disclosure and cognitive reappraisal, and by offering new perspectives.Social support from people with similar experiences is particularly valuable because individuals are more likely to incorporate new perspectives from people who have "been there." 12Social support indirectly facilitates PTG by providing a buffer against distress, which can lead to negative rumination about an event. 8Two recent systematic reviews on the correlates of PTG, one involving adult cancer survivors 13 and the other involving pediatric cancer survivors, 14 both found significant positive correlations between social support and PTG.However, both reviews defined social support as the functional provisions of relationships. 15This neglects the important effect that simply belonging and feeling connected to a group or community can have on a person's health, regardless of whether any social support is explicitly exchanged. 16cial connectedness is a basic need and type of belonging. 17,18It has been defined as an attribute of the self that reflects a subjective sense of enduring interpersonal closeness with people and society. 17cial connectedness is related to, but distinct from, perceived social support.Social support focuses on the availability of support in one's social environment, whereas social connectedness focuses on the emotional closeness or distance between the self and others. 17though they are different constructs, connectedness is likewise associated with psychological adjustment. 17Social connectedness gives life meaning and purpose, and is achieved when people feel seen, heard, and valued. 19YAs may be vulnerable to feelings of low connectedness as they often report feeling isolated and disconnected from family and friends who are unable to relate to their experiences. 20Connectedness to cancer peers can provide a unique sense of community 21 and may contribute to PTG.However, limited research has examined social connectedness among YAs and its impact on PTG.
The purpose of this study was to examine the relationship between connectedness and PTG among YAs.Our objectives were: (1)   To examine the association between feeling connected to the YA community and PTG; and (2) To determine whether overall social support and feeling connected to the YA community independently contribute to PTG.We hypothesized that greater feelings of connectedness to the YA community would be associated with higher PTG, and that connectedness to the YA community and overall social support would independently contribute to PTG.

| Participants
To be eligible to participate, YAs must have been diagnosed with cancer between the ages 15-39 and be 19 or older and residing in Canada at the time of the study.

| Survey procedures
The recruitment strategy involved a media campaign led by YACC that included paid recruitment ads targeting YAs on social media, radio, television, and print media.The survey was also distributed to YACC's national network of contacts including YAs impacted by cancer, clinicians, and other cancer support services.The online survey was launched in June 2017 and closed in March 2018.All participants provided informed consent as outlined in the digital consent form.

| Post-traumatic growth
PTG was measured using Tedeschi and Calhoun's post-traumatic growth inventory (PTGI). 8The PTGI is a 21-item instrument that assesses five dimensions of PTG: New Possibilities, Relating to Others, Personal Strength, Appreciation of Life and Spiritual Change.
Responses were measured on a six-point Likert scale, with higher scores representing greater PTG.The PTGI has been extensively used among cancer survivors and in studies of YA cancer survivors specifically. 22Similar to prior research, 9 we defined moderate-tohigh PTG as the upper 60% of the PTGI distribution which corresponded to a score of 51 or greater in this sample.

| Connectedness to the YA community
We measured feelings of connectedness to the YA community with the following one-item question that was created for the YACPRIME survey: "In general, how connected do you feel to the YA cancer community?"Responses were measured using a five-point Likert scale, ranging from "Not at All" to "Extremely."For the analysis, responses were categorized into: "Not connected" (Not at all) versus "Connected" (A little bit to Extremely Connected).

| Social support
Social support was measured using the Medical Outcomes Study Social Support Survey (MOS-SSS). 23The MOS-SSS is a 19-item instrument that assesses the perceived availability of four dimensions of social support: emotional/informational support; tangible support; affectionate support; and positive social interaction.It is not designed to assess social support from a particular source, but rather how often each kind of support is available from someone in your social network if needed.The survey instructions read: "How often is each of the following kinds of support available to you if you need it?"and an example survey item is: "Someone you can count on to listen to you when you need to talk."The responses were scored on a fivepoint Likert scale ranging from 1-None of the time to 5-All of the time.The scores were summed and scaled to an overall score ranging from 0 to 100, with higher scores indicating greater support.The MOS-SSS has been shown to be valid and reliable in a range of cancer populations. 24,25Like other studies, 26 we used the lower third of the sample distribution (score = 56.6/100.00)as the cut-off for low versus high social support.

| Demographic and clinical data
Demographic data collected included: age at the time of the survey, sex, race, and relationship status.Age was treated as a continuous variable.Relationship status was dichotomized into "in a relationship" versus single.Sex consisted of two options: male or female.Race was collapsed into broader categories and dichotomized as white or racial or ethnic minority for analysis purposes.Clinical data included cancer type and time-since-diagnosis. Time-since-diagnosis was treated as a continuous variable.

| Statistical analysis
Participant data and study measures were summarized using descriptive statistics and compared by social support group using independent t-tests for continuous variables and Chi-square tests for categorical variables.To evaluate factors associated with PTG, we used univariable and multivariable logistic regression to assess the unadjusted and adjusted effects of social connectedness to the YA community.Participant characteristics were included in the multivariable model as potential confounding variables.Separate models were evaluated for the full sample and each of the social support groups.To investigate whether social support and connectedness were distinct constructs, we compared level of connectedness among the low and high social support groups using a Chi-square test.Subsequently, we tested the interaction of social support and connectedness in the multivariable logistic regression model of PTG for the full sample.We controlled for age, time-sincediagnosis, sex, relationship status, and race/ethnicity in all multivariable models.All tests were two-sided and level of significance was set at 0.05.Analysis was conducted using R Statistical Software version 4.2.2.

| Participant characteristics
Demographic and clinical characteristics of the full sample and each social support group are presented in Table 1.In total, 444 individuals from the YACPRIME study were included in the analysis.
Respondents were on average 34 (SD = 6.0) years of age and 4.8 (SD = 5.4) years since their diagnosis.The most common diagnosis was breast cancer (28.4%).Most respondents were female (86.7%), in a relationship (70.3%) and identified as White (87.4%).Respondents who identified as White were more likely to report high social support compared to those who identified as a racial or ethnic minority (p = 0.01).Those in a relationship were more likely to report high social support compared to those who were single (p < 0.001).No other differences were observed in level of overall social support based on participant characteristics.

| Levels of connectedness and post-traumatic growth
In the full sample, 28.8% (n = 128) of individuals reported no connection, 27.9% (n = 124) reported feeling a little bit connected, and 43.3% (n = 192) reported being somewhat to extremely connected to the YA community (Table 2).Level of connectedness to the YA community did not differ by social support group.However, as shown in Table 2, individuals in the high social support group had significantly higher total PTG scores and higher "relating to others" sub-scale scores than those in the low social support group.

| Factors associated with PTG
The results of the univariable analysis are shown in Table 3.In the full sample, factors associated with moderate-to-high PTG were connectedness to the YA community, high social support, greater time-since-diagnosis, and female sex.In the high social support group, connectedness to the YA community and greater time-sincediagnosis were associated with moderate-to-high PTG.In the low social support group, the association between connectedness to the YA community and moderate-to-high PTG was not statistically significant.However, identifying as female or a racial or ethnic minority were associated with moderate-to-high PTG.
In the multivariable analysis (Table 4), connectedness to the YA community and greater-time-since diagnosis were associated with moderate-to-high PTG in all three models.Of note, the magnitude of the association between connectedness to the YA community and moderate-to-high PTG was higher in the low social support group (OR = 2.56, 95% CI: 1.19, 5.76) than the high social support group (OR = 1.75, 95% CI: 1.02, 3.01).In the full sample, high social support and female sex were also associated with higher odds of moderateto-high PTG.In the low social support group, identifying as female or as a racial or ethnic minority were also associated with higher odds of moderate-to-high PTG.The interaction term between social support and connectedness was not significant.

| DISCUSSION
Given their developmental stage, YA cancer survivors may be uniquely positioned to experience and benefit from PTG following a cancer diagnosis.This study revealed that YAs who feel connected to a community of YA cancer peers are more likely to experience In particular, YAs with low perceived social support but who feel connected to the YA community, and are female or a racial or ethnic minority have greater odds of experiencing moderate-to-high PTG.

Thus, identifying interventions to boost feelings of connectedness to
the YA community among YAs can contribute to positive psychosocial outcomes.
While it has been established that social support is integral to PTG, 8 to our knowledge, this is the first study to demonstrate a relationship between connectedness and PTG.Prior research (in the non-cancer community) has shown that social connectedness contributes to psychosocial outcomes that are related to PTG, such as self-esteem and well-being.For example, Lee and Robbins demonstrated that social connectedness was positively related to selfesteem and negatively related to trait anxiety among women. 27[30] Our study demonstrates that connectedness and perceived social support are unique constructs that independently contribute to PTG.This finding aligns with Lee and Draper's conceptualization of social connectedness. 17As mentioned earlier, they proposed that social connectedness is a dimension of belongingness that is distinct from perceived social support.However, Lee and Draper contend that certain dimensions of social support correspond with social connectedness, such as the social integration sub-scale of the Social Provisions Scale.Further, research is warranted to investigate these relationships.
Being female was associated with a higher odds of moderate-tohigh PTG in the full sample and in the low social support sample.This finding aligns with a meta-analysis of PTG in 70 studies, 31 that found a small to moderate effect of gender on PTG.Proposed reasons for this effect include differences in rumination and coping styles. 31udies have shown that females tend to engage in more positive and negative rumination than males. 31,32Rumination on constructive issues such as an awareness of personal strengths or the importance of social connections may be the mechanism leading to greater PTG in females. 12,31Females are also more likely to utilize emotion-focused coping strategies to manage stressors and related emotions, 33 which is proposed to be the core mechanism involved in the development of PTG. 12 Collectively these studies suggest that there are differences in how females and males cope with stress, as well as how they grow following traumatic events.
Identifying as a racial or ethnic minority was also associated with a higher odds of moderate-to-high PTG, but only in the low social support model.Other studies have shown that African-American breast cancer survivors report greater PTG compared to other groups.For example, a study of PTG in attendees of a breast cancer survivorship program in the United States found significantly higher PTG in African American women compared to White women. 34kewise, a cross-sectional survey of PTG in over 800 breast cancer survivors in the United States found higher levels of PTG among African-American women compared to White or Hispanic women.
Further, a sub-group analysis revealed that the relationship between race and PTG was mediated by religiosity. 35The authors hypothesized that the higher levels of PTG in African-American breast cancer survivors could be due to religious coping strategies or greater social support from the Church community. 35This underscores the importance of a wide social network and religious or spiritual community connectedness as a potential facilitator of PTG for some racial or ethnic minority individuals.

| Study limitations
This study has some limitations.Given the cross-sectional survey design, the timing of social support and PTG was not possible to discern.Self-reported information may be subject to social desirability bias; however, the anonymity of the survey likely reduced this possibility.The sample was predominantly female and White, which does not reflect the diversity of the Canadian population of YAs.This could be due to the use of online recruitment which has been shown to yield a less sociodemographic ally diverse sample of YAs in Canada than inperson, hospital-based recruitment in urban centers. 36In addition, the sample was in their mid-thirties and farther from diagnosis which may limit generalizability.Connectedness to the YA community was measured using a single item; a more robust multi-item measure of connectedness may more fully capture the nature and extent of connectedness for future study.Lastly, recruitment was conducted by YACC through its existing members and would presumably include many people who were connected to the YA community based on their use of YACC services.Hence studies conducted with different samples of YAs not connected to a cancer support organization may yield lower levels of connectedness to the YA community.

| Clinical implications
The results of this study illustrate that connectedness to the YA community is a unique source of support that contributes to PTG and the impact of feeling connected to the YA community may be particularly strong for YAs with low social support.The data also Data were obtained from the Young Adults with Cancer in their Prime (YACPRIME) study.This study was a collaborative patientoriented research project conducted in partnership with the nonprofit organization Young Adult Cancer Canada (YACC).The YACPRIME study consisted of a cross-sectional survey of the needs of YAs across Canada.It was conducted in accordance with the Declaration of Helsinki, and received ethical approval from Memorial University's Interdisciplinary Committee on Ethics in Human Research (ICEHR) #20170502-SC.

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MAH ET AL.moderate-to-high PTG, regardless of level of overall social support.In addition, YAs who have high perceived social support, are farther from diagnosis, and are female have higher odds of experiencing moderate-to-high PTG.However, YAs with low levels of social support are likely to benefit most from connection to the YA community.

444) High social support group (N = 293) Low social support group (N = 151) p-value b
Descriptive characteristics of the sample.
T A B L E 1 a Denotes statistically significant p-value based on alpha = 0.05.b p-value derived from Chi-square test for categorical variables and independent t-tests for continuous variables.c Estimate is comparing White and racial or ethnic minority groups.

Full sample Stratified by social support group High social support Low social support Odds ratio (95% CI) p-value Odds ratio (95% CI) p-value Odds ratio (95% CI) p-value
Levels of connectedness to the YA community and post-traumatic growth stratified by social support.
T A B L E 2 a Denotes statistically significant p-value based on alpha = 0.05.b p-value derived from Chi-square test for categorical variables and independent t-test for continuous variables.T A B L E 3 Univariable logistic regression of factors associated post-traumatic growth.a Denotes statistically significant p-value based on alpha = 0.05.MAH ET AL.

Full sample b Stratified by social support c High social support Low social support Odds ratio (95% CI) p-value Odds ratio (95% CI) p-value Odds ratio (95% CI) p-value
Multivariable logistic regression of factors associated with post-traumatic growth.adjusted for connectedness to YA community, social support, social support*connectedness to YA community, relationship status, time-since-diagnosis, age, sex, and race.connectedness to YA community, relationship status, time-since-diagnosis, age, sex, and race/ethnicity.show that there is a significant proportion of YAs who do not feel connected to the YA community, despite the existence of community organizations for YAs with cancer.Future work should overcome barriers to accessing community support organizations among YAs and examine the support preferences of YAs not adequately represented in this research.This may include YAs who are male and who identify as a racial or ethnic minority.Health care systems and community programs should expand support offerings that target the different mechanisms by which social relationships can enhance wellbeing.CONCLUSION Connectedness to a community of YA cancer peers was associated with moderate-to-high PTG, regardless of level of existing social support.In particular, YAs who had low perceived social support but felt connected to the YA community and identified as female or a racial or ethnic minority had the greatest odds of experiencing moderate-to-high PTG.Future research should examine how to increase access to YA cancer communities and foster a sense of connectedness among YAs with cancer.
T A B L E 4 b c adjusted for 5 |