Interpersonal Comparison Among Caregivers of Children with Asthma

Abstract

Objective:

We examined the extent to which caregivers of children with asthma used interpersonal comparisons—a novel comparison process that parallels social comparison and temporal comparison—to form judgments about their child.

Methods & Measures:

Using semi-structured interviews adapted from the McGill Illness Narrative Interview, we examined the interpersonal comparisons that caregivers of a child with asthma (n = 41) made regarding their child.

Results:

Interpersonal comparisons influenced caregiver thoughts, feelings, and behavior. They helped caregivers distinguish asthma from other breathing problems, evaluate the severity of the asthma, and understand their child’s experience. However, they also created uncertainty by highlighting the complex, unpredictable nature of asthma. Interpersonal comparisons were a source of gratitude and hope, but also worry and frustration. Finally, interpersonal comparisons influenced caregivers’ decisions and actions, resulting in decisions that aligned with and, at times, ran counter to biomedical models of asthma care. In some instances, caregivers used interpersonal comparisons to motivate their child’s behavior.

Conclusion:

The interpersonal comparisons served as a source of information for caregivers trying to understand and manage their child’s asthma. Investigating these comparisons also expands how we think about other comparison theories.

Asthma is a disease characterized by inflammation of the airways and affects over 6 million children in the United States [1]. It can be a complex and bewildering disease for caregivers of children with asthma for a multitude of reasons. It can be difficult to diagnose in young children [2] and intermittent or persistent in its symptoms [3]. The triggers, symptoms, and management strategies can vary across people [4], and the onset of an exacerbation can seem rapid and unpredictable [5]. The complexity of the disease creates challenges for caregivers trying to understand their child’s asthma and make the best decisions for their child’s care [6]. Caregivers can forge an understanding of asthma with help from clinicians [7], from any number of websites such as National Heart, Lung and Blood Institute website [8], and from personal experience caring for their child [9]. Yet, one important source of information that researchers have overlooked comes from interpersonal comparisons – caregivers’ comparisons of their child with others who have asthma. Interpersonal comparisons represent a previously overlooked type of comparison that can be a crucial source of information during times of uncertainty. These comparisons can inform how people should think, feel, and behave regarding a focal person. We use data from semi-structured interviews of caregivers of children with asthma to document interpersonal comparisons.

Pediatric Asthma and Interpersonal Comparisons

For over seven decades, researchers have theorized about the process by which people use comparisons to draw inferences about themselves. According to social comparison theory, people draw these inferences from comparisons with other people [10, 11], and according to temporal comparison theory, people draw these inferences from comparisons with themselves at other points in time [12]. We refer to the comparisons described by social comparison theory and temporal comparison theory as personal comparisons because the comparer is using comparison information to make personal inferences. Yet, people often make interpersonal comparisons to draw inferences about other people. Employers make judgments about employees, teachers make judgments about their students, and parents make judgments about their children. These interpersonal comparisons can be social (relying on comparisons with others) or temporal (relying on comparisons with the focal person at other points in time). Moreover, they parallel personal comparison processes in many ways.

With personal comparisons, the person making the comparisons (the comparer) is also the focal person of the comparison. Comparers draws inferences by comparing themselves with some referent. For example, people with asthma may draw inferences about the severity of their asthma by comparing their symptoms with the symptoms of others with asthma (a personal social comparison) or with the asthma symptoms they personally experienced at some other point in time (a personal temporal comparison). In contrast, with interpersonal comparison, the focal person is someone else, such as the child of the comparer, and the comparer draw inferences about the focal person in comparison with some referent. For example, parents of a child with asthma may draw inferences about the severity of their child’s asthma by comparing how their child’s symptoms compare with the symptoms of other children with asthma (an interpersonal social comparison) or with the asthma symptoms the child experienced in the past (an interpersonal temporal comparison).

Interpersonal comparisons are likely commonplace. Caregivers undoubtedly compare their child with other children both inside and outside the family, or with their child in the past, on topics ranging from developmental milestones to performance and achievement in school and in other settings [e.g., 13]. However, we found few studies that investigated interpersonal comparisons from the perspective of social comparison theory [10] and know of no study that has examined interpersonal comparisons within the context of understanding diseases such as asthma.

Childhood diseases such as asthma can create an array of personal and structural challenges for caregivers tasked with managing the disease. In the case of asthma, personal challenges include understanding when and how to use daily controller medicines [14], communicating with health professionals [15], distinguishing asthma symptoms from other health experiences such as anxiety, allergies, obesity, stress, or colds [6], and the presence in the family of multiple health problems that lead caregivers to de-prioritize their child’s asthma [16]. In the United States, these challenges are compounded by structural injustices that make it more difficult for caregivers with low income or who are members of marginalized racial or ethnic groups to care for their child’s asthma [17]. For example, due to racial segregation, economic inequality, and environmental injustice, caregivers who are Black or low-income may live in housing conditions that worsen children’s asthma symptoms [18], struggle to pay for healthcare needs [15], and lack the connections with medical providers needed for effective self-management of asthma [19].

The combination of personal and structural challenges can be significant sources of uncertainty and stress for families [20]. This uncertainty and stress can manifest in caregivers’ lives as attempts to control children’s environments in response to unknown asthma triggers, avoidance of locations in which people cannot control such triggers, or efforts to teach children how to manage asthma in the caregiver’s absence [17]. Importantly, researchers have long recognized that social comparison can provide information that reduces uncertainty and alleviates stress [10] and more recently have recognized that temporal comparisons help asthma patients determine how to best manage their symptoms when faced with triggers they recognize [21]. We propose that interpersonal comparison represents a parallel process that can help caregivers navigate their child’s asthma and respond to asthma-related challenges.

Thoughts, Feelings, and Behavior

Although we can imagine multiple ways to describe parallels between personal and interpersonal comparisons and to illustrate how interpersonal comparisons can influence caregivers, we focus on how they manifest in three psychological domains: thoughts, feelings, and behavior. This focus aligns with theoretical frameworks from various areas of psychology such as attitudes [22] and judgement and decision-making [23]. First, personal comparisons inform thinking. Festinger [10] originally described social comparison in terms of self-evaluation; people make social comparisons to gauge their current standing (e.g., How smart, attractive, athletic, etc., am I compared to other people?). Relatedly, research on fear and affiliation demonstrated that people may engage in social comparison to understand how they should feel [24]. And research on norms suggests that people may look to others to gain insights into how they should think and act [25, 26]. In a similar vein, we propose that people make interpersonal comparisons to help them evaluate the focal person. Thus, caregivers may evaluate the efficacy of a treatment for their child by comparing their child’s responses with the responses of other children with asthma who receive the same treatment. Caregivers may also use other children with asthma as referents to understand the likely triggers of their child’s asthma, the severity of their child’s asthma, and what symptoms represent asthma and what symptoms do not.

Second, numerous studies find that personal comparisons influence affect [e.g., 27]. Comparisons with others who are worse off can produce positive affect because of one’s superior relative standing [28, 29]. However, comparisons can also produce negative affect to the extent that people view the plight of the worse off target as a possibility for themselves [30]. Likewise, comparing oneself with others who are better off can produce negative affect because of one’s inferior standing [27, 31]. However, it can also produce inspiration and positive affect if people view the target’s superior standing as possible for themselves in the future [30, 32, 33], and can produce gratification to the extent that the comparer assimilates with the upward target [34]. We anticipate that interpersonal comparisons will function in much the same way. That is, how their child compares with other children and the interpretation they draw from the comparison will likely influence how caregivers feel about their child’s asthma.

Third, evidence suggests that personal comparisons can influence behavior. The clearest evidence comes from research on social norms, whereby other people serve as models for what decisions to make and what actions to take [35]. They provide information about what others typically do (i.e., descriptive norms) and information about what one should do (i.e., prescriptive norms) [36]. Normative information can form the basis of personal comparisons [26], and people rely on such information to guide their personal behavior [e.g., 37]. Although we know of no research on the topic, we propose that such information can also guide the decisions people make and the actions they take regarding others. For example, caregivers of children with asthma may make decisions about how to manage their child’s asthma based on what asthma management strategies appear effective for other children.

The Present Research

We conducted an initial exploration of interpersonal comparison that focused on what is perhaps the most common referent for such comparisons: parents making comparisons on behalf of a child. We explored these comparisons within the context of a chronic illness: pediatric asthma. Evidence suggests that uncertainty can be a powerful prompt for personal comparisons [24]. The uncertainty surrounding the triggers, symptoms, and treatment of asthma makes it a potentially fruitful arena for studying interpersonal social comparison.

We focused specifically on the cognitive, affective, and behavioral manifestations of interpersonal comparisons. We propose that interpersonal comparisons can yield valuable information to caregivers about how to think about their child’s asthma (e.g., how severe it is, and how to recognize symptoms), can inform caregivers how to feel about their child’s asthma (e.g., worry versus hope), and can guide caregivers in how they might respond (e.g., what actions will best manage their child’s asthma). We used a qualitative approach because it allowed us to examine the rich variety of responses to open-ended questions, rather than constraining responses to our preconceived ideas of what people do and existing theoretical frameworks that were not designed to capture how interpersonal comparisons operate. Qualitative interviews represent an important research tool in that they provide insights into thought and behavior with minimal direction or influence from the researcher.

To our knowledge, this study is the first to explicitly examine interpersonal comparisons. It pushes the boundaries of comparison theories by dramatically expanding how researchers can conceptualize comparison processes and by revealing an entirely new arena for research. It also pushes the boundaries of application by exploring a significant source of information people use when making inferences about or on behalf of others. Finally, it reveals new possibilities for interventions designed to improve health behavior and health outcomes that recognize that people often rely on interpersonal comparisons when making health decisions for their dependents.

Methods

The data for this study represent a subset of data collected via semi-structured interviews for the purpose of gaining in-depth understanding of how caregivers conceptualize, understand, and manage their child’s asthma. All research materials are available in the supplement at https://osf.io/ktrc5/?view_only=d4f43f55ecd44f27a2e07d4b46b6f3af (link anonymized for peer-review).

Participants.

We recruited caregivers of children with asthma. We received assistance with recruiting from the community recruitment enhancement teams of the participating universities. The recruitment enhancement teams maintain registries of community members who have expressed interest in research participation. The research team reached out to members of these registries by phone, posted announcements on social media sites, and placed flyers in relevant locations (e.g., pediatrician’s offices) to share study information with community members. Interested individuals were screened for eligibility: age ≥ 18, caring for a child (< 18) with asthma, and speaking English. Several months into recruitment we added eligibility criteria for low financial security and high asthma severity to increase the representation of these characteristics in our sample.

We aimed to recruit 40 caregivers or continue until the interviews reached saturation for the topics we were examining. The final sample included 41 caregivers from two U.S. cities (25 in St. Louis, MO, 16 in Gainesville, FL), 73% of whom were members of marginalized racial or ethnic groups (n = 33; Black = 30, Hispanic = 1, Asian = 1, Native American = 3; some participants fell into more than one group) and 78% of whom had low income (n = 32). In addition, 78% (n = 32) of the caregivers were mothers, 17.1% (n = 7) were fathers, and 4.9% (n = 7) were another family member (i.e., a grandmothers). Caregivers ranged in age from 23–62. No participants were excluded from the sample. We report additional details about the sample in the supplement. Participants received a $50 gift card for their time. We use pseudonyms when referring to specific caregiver responses in this report. Neither the study nor the analysis plan was preregistered. All participants consented to participate in the research.

Procedures.

All study procedures received approval from the two participating university review boards. Two interviewers in each location conducted 60-min audio-recorded semi-structured interviews between December 2018 and May 2019. Audio-recordings were professionally transcribed, checked for quality and to remove identifiers, and then uploaded into NVivo 12 for analysis. Our interview guide was based on the McGill Illness Narrative Interview (MINI) [38], a theoretically-driven, semi-structured interview protocol adaptable to specific health problems. We adapted the MINI to suit the aims of the broader project, which was intended to elucidate caregivers’ thoughts, feelings, and experiences about asthma management, exacerbations, treatment, and the effects of asthma on everyday life. The MINI allows researchers to elicit three different modes of representing and reasoning about illness: explanatory models, prototypes, and chain-complexes. JH, an anthropologist with experience adapting and using the MINI, adapted the guide to asthma caregiving with input from the full research team, which comprised asthma clinicians, psychologists, and anthropologists. Importantly for this paper, the guide’s section on prototypes included questions aimed at reasoning through analogy and through the experience of others. One question asked the caregiver to consider how their child’s asthma compares with the asthma of other children they know. However, caregivers made numerous interpersonal comparisons throughout the interview and not just in response this single item. The comparisons included comparisons with themselves, other adult family members, and with the focal child in the past and the future.

Analysis.

We began data analysis by identifying overarching themes in each interview and making connections among these themes as we continued interviewing. We constructed a thematic codebook based on our observational notes of the interviews, memos written while listening to the audio-recordings, and multiple readings of full transcripts. Once we finalized the codebook, which included 24 codes, team members double-coded each transcript and discussed discrepancies between coders. One code, titled ‘comparing asthma,’ served as the foundation for this analysis. We defined it to include any comparisons the caregiver made “…between the child’s asthma triggers, symptoms, management, and treatment and that of others. Includes abstract others or people known to them.” See the supplement for the codebook. We coded all interpersonal comparisons, irrespective of when they occurred during the interview.

To ensure rigor [39], we discussed researcher biases and reflexivity using debriefings and field notes and obtained and incorporated feedback from the full team. We regularly discussed how our disciplinary differences (e.g., as clinicians, anthropologists, and psychologists) and personal experiences (e.g., with caregiving, asthma, and structural advantages and disadvantages) shaped our perspectives and interpretations of the data.

Results

Within each of the three broad categories for understanding comparison processes (thinking, feeling, and behavior), we identified two themes. Regarding thinking, we observed that interpersonal comparisons help caregivers recognize and gauge their child’s asthma, and they helped caregivers understand their child’s experience. Under feeling, we observed that interpersonal comparisons can prompt the positive emotions of gratitude and hope, and they can also elicit the negative emotions of frustration and fear. Finally, under behavior, we observed that interpersonal comparisons can determine a course of action and lead to strategies for influencing the child’s behavior. We discuss in turn each category and the themes within each.

Interpersonal Comparisons Shape Thinking

Recognizing and gauging the disease.

The interviews revealed that interpersonal comparisons appeared to shape how caregivers understood their child’s asthma by guiding them to identify their child’s symptoms as asthma and by helping them distinguish their child’s asthma from other breathing problems. Caregivers reached these understandings by comparing their child with the children of others and with other children of their own. For example, Lisa, a Black mother of two children with asthma in St. Louis, described how she quickly identified asthma in her youngest son when he displayed symptoms similar to those she observed in her older son. “He was around the same age, around two or three years old, when we first noticed it. And I - I knew it because I knew all the signs for my oldest son.”

Twenty of our 41 caregivers reported a personal history with asthma and in many instances, caregivers used themselves as the referent for evaluating their child’s asthma. For example, Shonda, a Black mother in St Louis, heard her son’s ragged breathing and concluded that he had asthma rather than something else based on her personal experiences: “…that’s asthma. I know because I have it.” In a similar vein, Erin, a White mother from Gainesville, said she could identify an oncoming exacerbation in her daughter, saying “I can hear it cuz I know what I sound like... I feel the rattle in my chest when nobody else can. I can feel it like building up, so I know she can, too.” Choosing the self as the referent for evaluating the child’s asthma was both common and understandable. Asthma runs in families and the caregivers of children with asthma often have asthma themselves. It thus is quite natural that the caregivers would make inferences about their child’s asthma based on how the child’s experiences compare with their own experiences either currently or when the caregiver was a child.

Beyond interpreting breathing problems as asthma versus something else, caregivers drew on interpersonal comparisons to evaluate the severity of their child’s asthma based on a comparison of the symptoms, treatment, or restrictions in activity. Tuana, a Black mother from Gainesville who also had asthma, inferred that her son’s asthma was relatively severe because her son needed to use an inhaler daily whereas she did not. She said, “I can control mine. I don’t have to take my asthma pump every day. He has to take his every day.” In contrast, Liz a White and Native American mother in Gainesville, concluded that her son’s asthma was not severe because he, unlike his sister, did not need to take controller medication (long-term medication taken daily to control persistent asthma). Likewise, Nichole, a Black mother from Gainesville, concluded that her younger son had less severe asthma than his older brother because of his less frequent visits to the emergency department. And Desiree, a Black mother from Gainesville, reasoned that her son’s asthma was relatively non-severe because he “…doesn’t get as wheezy as most asthmatic people, like my brother.”

Using comparison information to evaluate asthma severity appeared crucial to caregivers. The availability of others for comparison could help caregivers to interpret if their child is doing well or poorly. Further, comparing the child’s current and previous experiences with asthma could reveal changes in asthma severity across time. Several caregivers made temporal comparisons, comparing their child’s current symptoms and treatment to their past experiences and treatment. For example, Liz described her son as very sick as a young child, with lungs full of fluid, but now just has “…a little mild wheeze that you kinda always hear.”

Understanding their child’s experience.

Thus far we have described how caregivers used interpersonal comparisons to recognize asthma in their child and to evaluate the severity of their child’s asthma. To understand their child’s asthma, several caregivers drew from their personal life, most often comparing the experience of their child with their personal experience with asthma. These comparisons allowed caregivers to sympathize, or even empathize, with their child. For example, Edith, a White mother with asthma from Gainesville, could relate when her child became sluggish, had trouble breathing, and did not want to do anything. Edith said, “I get it. I go there myself.” Similarly, Lauren, another White mother from St. Louis, commented about how her personal experiences with asthma prepared her for understanding her child’s experiences: “Whenever he had some little, you know, wheezing and stuff whenever he had a cold, um, it was pretty familiar territory.” Tom, an Asian father from St. Louis, compared his experience taking asthma medication with that of his son: “When I was a kid, we didn’t have those spacers. …you had to shoot the—that mist into your mouth, and it tasted like crap. And so, I actually can’t imagine him having to use it.” And Kelly, a White mother from Gainesville noted, “I remember quite a few times physically crying, um, because I had to take my breathing treatment—as a child, and I, um—it was just hard, so I know—I can feel his pain, but I’m like, ‘You have to do this, kid.’ [Chuckles] ‘You know? You’ll feel better.’” By using themselves as the referent, caregivers could better understand their child’s experience with asthma.

Caregivers who had personally experienced asthma drew on those experiences to gain insights into their child’s experiences; their personal experiences helped the caregivers put themselves in their child’s shoes. Yet, even caregivers who did not have asthma attempted to draw from personal experiences to understand their child’s experience, as illustrated by Rebecca, a White mother from St. Louis.

“I can imagine what it’s like. I did scuba diving, so that’s the only thing that I can equate that was close to it. I didn’t like that feeling of that pressure—and like you couldn’t breathe even though you’re breathing. So that’s what I remind myself of, what that was like. Now, I didn’t freak out. I’m just like, ‘I want up top.’ And I could just go up top. And, of course, you knew it would be over, whereas for him, you know, I guess he’s freaking out because he doesn’t know, you know, when the end is.”

Although Rebecca used her experiences with scuba diving to understand her child’s fears, she recognized that her diving experience was an imperfect analogy. Rebecca knew that she could escape the fear she experienced breathing under water and that her anxiety would end once she surfaced. She also recognized that her child had no such assurance because he could not predict when an exacerbation would end.

This last illustration speaks to an important insight that many caregivers distilled from interpersonal comparisons regarding asthma. Although the comparisons can provide clarity and understanding, they also can be a source of confusion, revealing that asthma can be unpredictable. In some instances, unpredictability surrounded the experience of symptoms—when will they occur and how long will they last—as illustrated in the example from Rebecca just described. More often, the unpredictable nature of asthma emerged from interpersonal comparisons with the caregiver’s personal experiences with asthma, the child’s asthma experiences at other time points (i.e., temporal comparisons), and the experiences of others with asthma such as a caregiver’s other children, family members, and friends. Erin, a White mother from Gainesville described earlier, felt her daughter’s asthma defied expectations. She believed that most children outgrew asthma and was troubled that her 17 year-old daughter had not. In her words, “My 18-year-old son, he had some breathing problems. Not diagnosed as asthma, but he had an inhaler as emergency inhaler—and he outgrew it. And here she is just not outgrowin’ it.” Pamela, a Black mother from Gainesville, also commented on the unpredictability of asthma, noting that, “Most people think asthma affect everybody the same… His asthma [is] nothing like the relative that I know.” Echoing this same theme was Rachel, a Black mother from Gainesville who said, “Triggers vary across children, which is a source of frustration: but it’s harder cuz the triggers aren’t the same.”

In some instances, an early, personal experience or memory functioned as the referent when evaluating their child’s asthma. Caregivers lamented that the triggers and their child’s reaction to them were often unexpected or unreliable. They felt they did not know when or what kind of reaction might happen. In the words of Tuana, “like only thing that really triggers mine is pollen or when I catch a—when I catch a cold…But his is the total opposite…I can control mine.”

Summary.

When viewed together, the reports from caregivers revealed that interpersonal comparisons helped shape their thinking about their child’s asthma and gave them insights into their child’s experiences. The comparisons aided caregivers in interpreting their child’s symptoms and provided them a means to evaluate the severity of their child’s asthma in general. They also enhanced caregivers’ understanding of their child’s subjective experience. Finally, the comparisons demonstrated to caregivers how their child’s asthma could be unpredictable.

Interpersonal Comparisons Influence How Caregivers Feel about Their Child’s Asthma

Gratitude and hope.

A recent meta-analysis of personal social comparisons revealed that people prefer upward comparisons over downward comparisons [40]. In our interviews, caregivers seemed evenly split in the frequency with which they made interpersonal comparisons of their child with a referent who was faring worse versus faring better. Moreover, as evident in Table 1, the interviews revealed that the interpersonal comparisons expressed by caregivers had both positive and negative affective consequences. Specifically, interpersonal comparisons with a referent who fared worse than the caregiver’s child were occasionally accompanied by expressions of gratitude, suggesting that participants may have derived affective benefits from the favorable interpersonal comparison. For example, Kimberly, a Black mother from Gainesville, repeatedly remarked on how thankful she was that her child’s asthma was not as bad as the asthma of other people she knew. She said, “I know, a couple people that have passed away from having asthma attacks. And so, I’m just thankful and, uh—and prayerful.” Such grim comparisons can provide comfort even for caregivers who have children with severe asthma: caregivers can feel solace that their child is alive. Of note, her “prayerful” comment suggests that she was also fearful of the possibility that her child’s asthma could worsen.

Table 1.

Affective Consequences of Interpersonal Social Comparisons

Type of Interpersonal Social Comparisons	Positive Affective Consequence	Negative Affective Consequence
Downward (Comparing one’s child with others who are faring worse)	Gratitude that one’s child faring better than others (Pride that one’s child has…)	Fear that one’s child might share same unfavorable outcome seen in others
	I’m thankful that it’s a slow progression for him when he’s reactive. It’s not like he just automatically—cuz some people, they—it’s almost like anaphylactic shock.	Her dad’s is bad. So—and I—I don’t want my baby’s to get bad.
Upward (Comparing one’s child with others who are faring better)	Hope that one’s child would have a better future	Frustration that one’s child is not doing as well as expected
	As Luke got older… they [the exacerbations] became less, you know frequent, you know… So maybe it’s gonna…I hope so.	Normally, the kids I’ve known that have asthma, they normally outgrown it. Hers hasn’t.

In addition to comfort, the interpersonal comparisons offered caregivers a reason to have hope for the future. For many children, asthma symptoms diminish with time. For example, older children with asthma experience fewer symptom days, symptom nights, and emergency department visits than do younger children with asthma [41]. Some of the caregivers were aware that asthma symptoms can diminish with age and expressed hope that their children would eventually experience a reduction in symptoms as well. This hope is apparent in the quote in the bottom row of Table 1, which describes the desires of Andre, a Black father from Gainesville, for a future in which his child has fewer symptoms: “As Luke got older… they [the exacerbations] became less, you know frequent, you know… So maybe it’s gonna…I hope so.”

As a result of interpersonal comparisons, some caregivers wished for other things as well, such as that their children could manage their own asthma. For example, Nicki, a Black mother from St. Louis, recalled the proactive actions of another child receiving asthma medication from a school nurse. Nicki wished for the day when her child could detect an oncoming asthma exacerbation before the symptoms became severe. “I want my Nathan to be like that…I want him to [say], ‘Something does [not] feeling right… Can I go get my medicine?’” These findings parallel findings from the literature on personal comparisons. Researchers have suggested that learning about others who are faring better can provide hope and inspiration [32]. For example, these comparisons can increase feelings of competence and motivation among people who believe their situation can improve [33]. It also can provide a glimpse of an alternative, better world to strive for. Managing Nathan’s asthma was a burden for Nicki that could be lifted were Nathan able to manage his asthma like other children.

Frustration and fear.

Similar to research on personal social comparison, both comparisons with others who are faring better and comparisons with others are who are faring worse corresponded with negative affective consequences among caregivers. Some caregivers we interviewed reported frustration and fear in response to comparisons with others who were faring better. For example, caregivers were frustrated when, contrary to their expectations, their child had not outgrown their asthma. Caregivers were fearful when discussing concerns that their child might experience the same undesirable outcomes as the referent. For example, Tasha, a Black and Native American mother from St. Louis, feared that her daughter Kayleigh would experience asthma symptoms as bad as Kayleigh’s father: “Her dad’s is bad. So—and I—I don’t want my baby’s to get bad.” And William, a Black father from Gainesville, feared that his son might become like the father’s uncle, who he viewed as excessively dependent on others to take care of him when he experienced asthma symptoms: “And he still acts like a two-year-old when - when it comes to asthma. ‘Oh, I can’t breathe. Oh, I need—’ His mom still babies him.” In contrast, William aimed to teach his own child to respond differently to his asthma symptoms. “You have a problem, deal with it, and move on. Fix the problem and keeping going.” By so doing, William felt he could steer his child away from also becoming excessively dependent on others to care for his asthma.

Summary.

Stepping back, the interviews revealed similarities and differences between personal and interpersonal comparisons in terms of their affective consequences. We did not observe an inclination for caregivers to compare more with others who were faring better than with others who were faring worse. Nevertheless, and consistent with research on personal social comparison, both interpersonal comparisons with others who were faring better and others who were faring worse had positive and negative affective consequences [32, 42].

Interpersonal Comparisons Guide Decisions and Behavior

Determining a course of action.

We found evidence that caregivers used interpersonal comparisons to influence decision making and behavior. Caregivers compared their child’s asthma with the normative information provided by other caregivers (e.g., what are common triggers, symptoms, and management strategies), and then made decisions and took actions based on those comparisons. Sometimes the decisions departed from the biomedical model for treating asthma, which emphasizes pharmacological treatments. For example, Kimberly described the daughter of a cousin who “takes honey by mouth every day…[and] has no more allergies, no more asthma… She has not had asthma in like over five years.” This interpersonal social comparison led the caregiver to view honey as a viable treatment for her child.

In some instances, the interpersonal comparisons actually dissuaded caregivers from following biomedical treatments for asthma. Several caregivers expressed concerns about weight gain associated with taking corticosteroids. As Nichole explained, “We don’t do the steroids for the entire, um, prescribed time because the weight issues is a big concern for us. And we know he’s active, but we just have actually saw other kids who are really overweight cuz of they asthma, you know, the steroid.” This example illustrates the powerful influence interpersonal comparisons can exert on treatment decisions.

As noted in the section on how interpersonal social comparison can shape thinking, caregivers often used themselves or other family members as the referent for interpersonal comparisons. They described how their personal experience with asthma shaped the treatment decisions they made for their child. If a particular treatment approach worked for the caregiver as a child, the caregiver pursued the same approach with their child. In some cases, the caregiver described how their personal suffering with asthma as a child persuaded them to take a different, or perhaps more aggressive, approach to treating their child’s asthma symptoms. Kelly, a White mother from Gainesville, recalled how she struggled with uncontrolled asthma as a child and thus chose to respond earlier and more comprehensively when her child displayed symptoms. “I was like, ‘No, we’re gonna pursue care for this early—so that way we don’t have any problems.’” Christina, a Black mother from St. Louis, revealed that her personal experience with asthma taught her to be “…vigilant about the things that I buy.” She avoids “certain body washes” that have scents that might irritate her child’s breathing. In each of the instances reported, the caregiver’s personal experiences guided their treatment decisions and behavior related to their child’s asthma.

Influencing the child’s behavior.

Although uncommon, we observed some instances in which caregivers used interpersonal comparisons to influence the child’s behavior. These attempts typically involved reminding the child of someone who was faring worse and noting how the child could experience similar outcomes if not careful. For example, Monique, a Black mother in Gainesville described attempts to persuade her daughter to watch her eating and weight gain when taking steroids:

I used to tell her, “Remember, when-when Troy was your age and he end up, you know, with asthma? And then, later on, he end up having—you know, he end up being a diabetic.” I keep telling her, “You don’t want to end up the way he was cuz look-look how—the path he took.”

These instances reflect caregivers’ recognition that they cannot always control the child’s behavior directly. However, they may influence the child’s behavior indirectly by making a particular comparison salient, one that illustrates a possible unwanted future. This finding is reminiscent of research relevant to personal temporal comparison whereby people’s thinking about a future self can influence how they feel and behave in the present [43]. Likewise, William, the Black father described earlier, used a past, embarrassing episode in the child’s life (collapsing in front of other people during an exacerbation) as the referent to motivate his son to take his medication when he had breathing problems. In his father’s words, “We keep this event fresh in his mind…” so that it does not recur. This statement suggests that caregivers may employ interpersonal comparisons to guide their children’s behavior towards actions that may better manage their asthma.

Summary.

As our data suggest, interpersonal comparisons were more than interesting mental activities that caregivers displayed when contemplating their child. Caregivers used the comparisons to inform their decisions and behavior. Often, caregivers turned to interpersonal comparisons to make asthma treatment and management decisions. Moreover, the importance of these interpersonal comparisons was evident in how they prompted caregivers to take specific action, and in how they persuaded caregivers to depart from biomedical treatments. Our observation that caregivers used interpersonal comparisons to influence their child’s behavior suggests that caregivers also recognized the power of such comparisons.

Discussion

Asthma creates numerous challenges for caregivers and their families, such as difficulties avoiding or managing triggers, determining asthma symptoms, making treatment decisions, deciding when to seek asthma-related care, and accessing quality medical care for asthma. We proposed that caregivers rely on interpersonal comparisons to provide information to deal with the challenges. Researchers have largely overlooked interpersonal comparison in understanding how caregivers come to terms with and respond to their child’s asthma. Yet our research suggests that the comparisons can be a vital source of information.

How Interpersonal Comparisons Operate in the Real World

Our investigation revealed that interpersonal comparisons can influence how the comparer thinks, feels, and behaves. In our specific study, interpersonal comparisons shaped caregiver thinking by helping them to recognize that their child had asthma, to distinguish asthma from other breathing problems, to determine the severity of their child’s asthma, and to provide a foundation for understanding their child’s experience with asthma. However, interpersonal comparisons also created uncertainty insofar as they forced caregivers to recognize asthma as a complex, unpredictable disease. Perhaps most important, interpersonal comparisons are crucial to the formation of judgments. In the absence of referents, caregivers may misjudge their child (e.g., assuming their child’s asthma is typical when it is not) because they lack exemplars against which they can gauge their child’s experience.

Interpersonal comparisons also influenced how caregivers felt about their child’s asthma. Comparing their child with others who had asthma elicited positive feelings such as gratitude when caregivers concluded that their child’s asthma was not as bad as the asthma of others, and hope when the interpersonal comparisons suggested a possible positive future for their child—a future with diminished symptoms. Interpersonal comparisons also elicited worry over how bad their child’s asthma could become and frustration if caregivers’ positive expectations regarding improvement of symptoms were not met. Finally, the reports from caregivers suggested that interpersonal comparisons influenced the decisions they made and the actions they took, occasionally resulting in decisions that ran counter to biomedical models of asthma care. Caregivers also occasionally used interpersonal comparisons to motivate their child’s behavior.

Our findings suggest that interpersonal comparisons play an important role in caregivers’ management of their child’s asthma. Caregivers often struggle to recognize when a child’s symptoms result from asthma or some other health problem [6]. Our findings reveal that caregivers used interpersonal comparisons to interpret their child’s symptoms and to evaluate the seriousness of their child’s asthma. Caregivers also struggle with responding to symptoms in the moment and managing their child’s exposure to triggers and experience of symptoms over time [6, 14, 16]. The caregivers in our study turned to interpersonal comparisons to make asthma treatment and management decisions. They also used these comparisons to learn about nonpharmacological, home remedies for asthma symptoms. Perhaps most importantly, asthma is a complex disease that can vary markedly from person to person [4]. The complexity is a source of tremendous uncertainty for caregivers [20]. Although we found that interpersonal comparisons occasionally created greater uncertainty about the disease, the more common finding was that interpersonal comparisons helped caregivers better understand the disease, and to manage and treat the symptoms in their child.

Research shows that contextual factors such as poverty, racism, and environmental injustice can affect how caregivers respond to asthma [14, 16, 44]. For example, caregivers with higher income may work to align themselves with medical providers whereas caregivers with lower income may experiment with home remedies [19]. Likewise, caregivers whose children attend well-funded schools may alter school systems to accommodate their child’s asthma, whereas caregivers with children at under-funded schools may bypass school structures to help their child [18]. Finally, caregivers who are Black and live in unsafe neighborhoods may rely more on community support to manage their child’s asthma [45]. Within these contexts, caregivers who lack resources or outside support may depend on interpersonal comparisons in deciding how to care for their child’s asthma. Perhaps interpersonal comparisons are an especially important source of information for caregivers dealing with childhood asthma in these challenging contexts.

Because our investigation focused on the disclosures of caregivers during semi-structured interviews, it likely did not account for the broad array of circumstances in which caregivers use interpersonal comparisons when thinking about their child’s asthma. We suspect other methodologies including ethnographic or survey approaches might reveal broader and more extensive use of interpersonal comparisons among caregivers attempting to understand and manage their child’s asthma. For example, caregivers—particularly Black caregivers—face challenges managing their child’s asthma in their homes and neighborhoods and accessing asthma care for their child [15, 18, 45, 46]. We suspect that more directed questions would reveal a fuller picture how caregivers use interpersonal comparisons to respond to these challenges.

Implications

Our findings have practical and theoretical implications. From a practical perspective, our interviews revealed that people use interpersonal comparisons to understand and make decisions about a focal person, and that the comparisons can affect how they feel. Providers may find it helpful to thoughtfully investigate whether and with whom caregivers are making comparisons. Such questions could initiate discussions of uncertainty and concerns about their own child’s asthma and treatment course. In instances where caregivers compare their child with inappropriate targets, the provider could offer information about what most children with asthma experience, thereby reorienting the caregivers toward more appropriate interpersonal comparison targets. Or providers perhaps can couch recommendations and advice within the interpersonal comparison context, much the same as caregivers did when trying to motivate their children with asthma (e.g., “Here is what other caregivers do to help their child deal with asthma symptoms.”). Such interpersonal comparisons could inspire hope and encourage adherence to proven medical treatments and facilitate communications with caregivers who feel disconnected from providers because of social, economic, and environmental factors. They may also be more persuasive to caregivers to the extent that the information is concrete, vivid, and memorable [47]. The practical implications we describe are largely speculative at present but pose an exciting direction for future research.

From a theoretical perspective, our approach expands how we conceptualize comparisons. Theories of personal comparison focus on the self, who is both the comparer and the focal person in the comparison, and in the case of personal temporal comparisons, the referent. The comparer evaluates his or her standing through comparisons with others [10, 11, 29] or with the self at some other point in time [12]. In contrast, with interpersonal comparisons, the comparer is not the focal person. Rather, someone else—in our study, a child—occupies this central role, and the caregiver compares the focal person with a referent. In several instances, the comparer was the referent. However, in these instances, the child remained the focal person; caregivers merely used themselves as a comparison target to gain insights about their child. To be sure, we also observed (but did not report here) instances of caregivers displaying personal social comparison, comparing themselves with other caregivers and comparing themselves today with how they were in the past. However, these personal comparisons were not the focus of our research.

Strengths, Limitations, and Future Directions

We conducted this research with a sample that was socio-demographically and economically diverse (i.e., by age, race/ethnicity, and geography) and addressed a serious health condition that affects millions of children in the U.S. (i.e., asthma). Nevertheless, it is possible that a different sample, a different health condition, or a different comparer would have yielded different information about the relevance of interpersonal comparisons on people’s thoughts, feelings, and behavior. Although we believe research on interpersonal comparisons has potentially broad theoretical applications, the generalizability of the findings from our qualitative study is constrained to families with one or more asthmatic children residing in St. Louis, MO and Gainesville, FL [see 48]. Nevertheless, the qualitative interviews we described represent an initial exploration of interpersonal comparisons. Qualitative interviews represent a powerful research tool in that they provide insights into thoughts and behavior. They are not meant to be representative or to provide evidence regarding the prevalence of thoughts or behavior within the population. In our case, they expand theorizing in ways not previously considered (e.g., by demonstrating that people rely on interpersonal comparisons, that interpersonal can be social or temporal, and that comparers sometimes use themselves as referents in interpersonal comparisons).

Our study merely scratches the surface of interpersonal social comparison, and more research is needed. We describe several potentially fruitful directions. First, quantitative procedures such as surveys and experiments would be useful for triangulating our findings. They also might help identify when and why interpersonal and personal comparisons are similar versus different. Second, unlike other research [40], we found no evidence that caregivers more frequently compared their child with a referent who fared better than a referent who fared worse. However, our sample was small and not designed for making quantitative comparisons. It is possible that caregivers showed no preference for making comparisons with children faring better (i.e., “upward interpersonal comparisons”) because the motivation to obtain useful, accurate information superseded the motive to obtain information that might feel good or boost self-esteem [49].

Third, we noted that caregivers’ interpersonal comparisons were linked to both positive and negative affective experiences. But the specific emotions reported by caregivers were limited, possibly because we did not ask explicitly about affect in the context of interpersonal comparisons. Most notably absent in the caregiver reports were the esteem consequences of making interpersonal comparisons, which some researchers have suggested underlies some forms of interpersonal comparisons [50]. Although caregivers in our sample reported feeling gratified when reflecting on others who had more severe asthma than their child, it is unknown whether making comparisons with children who fared worse (i.e., “downward interpersonal comparisons”) boosted caregivers’ self-esteem.

Finally, theorists have suggested that several motives (e.g., self-enhancement, self-verification, self-improvement) can motivate personal comparisons [32, 51]. Our study illustrates how caregivers used interpersonal comparisons for evaluative purposes—to evaluate their child’s standing relative to other children and to evaluate the severity of their child’s symptoms. We found no evidence for other motivations underlying interpersonal comparisons, nor was our study designed to do so. However, we can imagine people using interpersonal comparison for self-enhancement (e.g., to reach desired conclusions about their child), self-verification (e.g., to confirm beliefs about their child), or improvement (to find ways to achieve better outcomes for their child). Demonstrating these alternative motives would be an important direction for future research, particularly if they could be harnessed in intervention research designed to improve health outcomes.

Conclusion

Caregivers face a host of challenges managing their child’s asthma. Our research describes an uninvestigated form of comparison—interpersonal comparison—caregivers can use to understand and respond to their child’s asthma. Interpersonal comparisons function in much the same way as personal comparisons. They shape how and what caregivers of children with asthma think, influence how they feel, and guide their decisions and behavior. Perhaps most importantly, interpersonal comparisons represent a source of information that caregivers rely on when forming understandings of and managing their child’s asthma. Our study represents an initial exploration of interpersonal comparisons, one that we hope will prompt more research.