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. 2023 May 17:1–11. Online ahead of print. doi: 10.1007/s10880-023-09956-2

Friends’ Perspective: Young Adults’ Reaction to Disclosure of Chronic Illness

Eva C Igler 1,2,✉, Jillian E Austin 3,4, Ellen K D Sejkora 5, W Hobart Davies 1
PMCID: PMC10189708  PMID: 37195582

Abstract

Chronic illness can negatively impact adolescents’ and young adults’ social support. Social support can buffer the negative impact of living with chronic illness. The purpose of this study was to test the acceptability of a hypothetical message to promote social support after a recent diagnosis of a chronic illness. Young adults (18–24; m = 21.30; N = 370), the majority of which were Caucasian, college-students, and female, were asked to read one of four vignettes and to imagine this situation happened while they were in high school. Each vignette contained a hypothetical message from a friend diagnosed with a chronic illness (cancer, traumatic brain injury, depression, or eating disorder). Participants answered forced-choice and free-response questions asking about the likelihood they would contact or visit the friend, and feelings about receiving the message. A general linear model was used to assess quantitative results, and qualitative responses were coded using the Delphi coding method. Participants responded positively, reporting a high likelihood to contact the friend, and feeling glad to receive the message regardless of vignette viewed; however, those who read the eating disorder vignette were significantly more likely to express discomfort. In qualitative responses, participants described positive emotions associated with the message and desire to support the friend. However, participants reported significantly greater discomfort with the eating disorder vignette. The results provide evidence for the potential of a short, standardized disclosure message to promote social support following chronic illness diagnosis with some additional considerations for those recently diagnosed with an eating disorder.

Keywords: Chronic illness, Social support, Young adult mental health

Introduction

More than 2 in 5 children and adolescents aged 6–17 years-old meet criteria for a chronic illness (e.g., epilepsy, diabetes, asthma) in the United States (CDC, 2022) and approximately half of young adults (18–34) report living with a chronic illness (e.g., obesity, depression, high blood pressure; Watson et al., 2022). For the purposes of this manuscript, a chronic illness is considered any illness lasting long enough to have a significant impact on an individual’s current and future functioning. Previous research demonstrates how chronic illness diagnoses and treatments result in increased social difficulties (e.g., Rueger et al., 2016; Taylor et al., 2008). Peer relationship difficulties have been demonstrated in children and adolescents with cancer (Patenaude & Kupst, 2005; Sodergren et al., 2017), neurological conditions (Benson et al., 2015; Martinez et al., 2011), sickle cell disease (Noll et al., 2010), depression (Gao et al, 2022; Rueger et al., 2016), and eating disorders (Makri et al., 2022; Murray, 2019; Patel et al., 2016). Additionally, adolescents and young adults with mental health diagnoses may be especially at risk for reduced peer support and poorer self-efficacy due to worsening relationships and reduced peer support associated with increased stigmatization (Elkington et al., 2012; Wang et al., 2022). Please note, authors use the term “peer support” to refer to physical, social, and emotional support provided by friends or peers.

The negative impact of chronic illness on peer support may be exacerbated during adolescence and young adulthood, as this time is associated with increasing importance of peer support (Sodergren et al., 2017; Taylor et al., 2008). Chronic illness can have a significant impact on typical adolescent and young adult peer relationship patterns; however, this impact can be buffered by peer support (La Greca, 1992; La Greca et al., 2002; Papadopoulos & Papkonstantinou, 2020; Rueger et al., 2016; Taylor et al., 2008). Greater peer relationship quality decreases adjustment difficulties for those with chronic physical and mental illnesses (Gao et al., 2022; Pisula & Czaplinska, 2010; Rueger et al., 2016). Maladjustment is less likely when the individuals reports greater peer acceptance, more friends, and better friendship quality (Papadopoulous & Papkonstantinou, 2020; La Greca et al., 2002).

In chronically ill populations, friendships among adolescents with similar conditions and diagnosis-specific mentoring programs have demonstrated positive impacts, such as providing emotional support and giving adolescents a safe space to discuss their condition (Forgeron et al., 2015; Kohut et al., 2018). However, children and adults with a chronic physical and mental illnesses often report having difficulty discussing their illness with their friends (Kirk & Hinton, 2019; Sannon et al., 2019; Taylor et al., 2008), diminishing the opportunity for peer support and increased relationship quality. Recent research has demonstrated individuals may often attempt to hide or conceal their new diagnosis as a way to preserve their pre-illness relationships and identity (Camacho et al., 2020; Kirk & Hinton, 2019). Previous work has demonstrated that friends of an individual diagnosed with a chronic illness identified communication as one of the biggest hindrances to maintaining friendships when a friend is diagnosed with a chronic illness (Igler et al., 2019; Kirk & Hinton, 2019).

Despite the evidence that a chronic illness is negatively associated with peer relationships and peer support, there are few interventions specifically targeting peer support promotion (e.g., Greco et al., 2001; Wilkerson, et al., 2017). Often interventions target several psychosocial concerns rather than focusing on improving peer support or increasing communication with peers (e.g., Moola et al., 2014). Notably, research on disclosure of a chronic physical or mental illness, particularly invisible illnesses, has demonstrated considerable benefits (Camacho et al., 2020; Sheehan et al., 2019).

The COVID-19 pandemic saw a significant increase in mental health concerns for children and young adults (CDC, 2022; Elharake et al., 2022; Lee et al., 2020). Further, there is evidence this is particularly true among individuals with chronic illnesses (Samji et al., 2022). Social isolation resulted in a decrease in social interactions adolescents and young adults would naturally have at school and the work place (CDC, 2022). Individuals began to rely more on virtual forms of communications for peer support throughout the pandemic, and recent research has demonstrated the positive impact peer support via text message or social media has had throughout social isolation (e.g., Suwinyattichaiporn & Turner, 2020). Additionally, research has provided evidence for the positive effects of disclosure and communication regarding chronic illness experience via social media platforms (Sannon et al., 2019). In contrast, relatively little is known about the receiving peer’s perspective of, or response to a friend’s chronic illness diagnosis. Understanding peer responses to diagnosis disclosure may assist in the development of an effective social support intervention.

Creation of a simple intervention that promotes peer support and communication may be particularly useful, as rigorous multi-faceted psychosocial interventions requiring frequent access to professionals and novel digital technology are difficult to disseminate and implement in the community (Lau et al., 2020). Specifically, the field could benefit from a non-disease specific intervention delivered via digitally-mediated communication (e.g., text message, snapchat, social media direct message) and implemented by diverse medical support personnel including clinical psychologists.

The purpose of this study was to test the acceptability of a hypothetical short message from a friend recently diagnosed with a chronic physical or mental illness from a peer’s perspective as a first step towards developing a general method to promote friendships and peer support across several chronic illnesses. Participants were asked to respond to the message as if they were in high school in order to capture a time of particular importance of peer support (e.g., Taylor et al., 2008). Messages representing four different illnesses were examined (cancer, traumatic brain injury, depression, and an eating disorder) to determine potential differences in friends’ responses to physical and mental health issues. It was hypothesized that participants would be accepting of a short message overall, demonstrated by feeling glad and comfortable to receive the message. It was also hypothesized that participants would be more uncomfortable when receiving a hypothetical message from a friend recently diagnosed with a mental health disorder, as research has demonstrated that social stigma is particularly prevalent for adolescent diagnosed with a mental illness (e.g., Elkington, et al., 2012). Finally, it was hypothesized that females would be more accepting of the message than males, as females are more likely to use social support to cope with stress (Pisula & Czaplinska, 2010).

Methods

Participants

Young adults (N = 370), ages 18–24, completed an online survey through SurveyMonkey.com. The majority of participants were female (56.2%), full-time students (57.3%), and identified as Caucasian (72.8%). The participant mean age was 21.39 years (SD = 1.79). See Table 1 for complete demographics.

Table 1.

Participant demographics

Variable N Percentage
Gender
 Female 207 56
 Male 160 43
 Non-binary gender identity 3  < 1
Student status
 Full-time college student 213 57
 Non-student 112 30
 Part-time college student 33 9
 High-school student 13 4
Race/Ethnicity
 Caucasian (non-Hispanic) 270 73
 Latinx 30 8
 African American 28 8
 Mixed race 21 6
 Asian 11 3
 Native American 2  < 1
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*Percentages may not equal 100% due to rounding

Procedure

The current study procedures followed ethical standards and were approved by the Institutional Review Board at a large Midwestern University in the United States. Participants completed a self-report survey as part of a larger online study. Students enrolled in an upper-level psychology course recruited participants as a course requirement. Students recruited individuals that were 18–24 years-old and English speaking, regardless of student status or other demographic factors. This was done in order to recruit participants other than only undergraduate students. Students could complete an alternative assignment if unable to recruit participants. Participants were provided with a link to the study and were asked to confirm they were at least 18-years-old and complete informed consent upon visiting the survey webpage. Participants were randomly assigned to read one of four vignettes, each differing by the type of diagnosis (cancer, traumatic brain injury, depression, eating disorder). Each vignette contained an identical message from a hypothetical friend that had recently been diagnosed with one of the diagnoses (Fig. 1). Participants were asked to imagine they received this message from a friend when they were a junior in high school and were asked questions regarding their reaction to the disclosure. Participants then responded to a series of forced-choice and open-ended questions, as described below. The questions outlined below were specifically created for the study.

Fig. 1.

Fig. 1

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Vignette from a hypothetical friend recently diagnosed with cancer, a traumatic brain injury, depression, or an eating disorder

Measures

Background

Participants first provided demographic information including gender, age, student status, education level, and race/ethnicity.

Peer Message Acceptance

The term acceptance is used to identify a likelihood participants would feel glad and be comfortable receiving this message. After reading the vignette, participants answered closed and open-ended questions. The survey was specifically created for the current study. Participants answered a total of four quantitative and three qualitative questions. The first two questions asked participants to rate the likelihood they would visit their friend and the likelihood they would call/text/contact their friend after receiving the message (scale 1–10, 1 = not at all likely and 10 = absolutely would). The next two questions asked participants to rate on a scale from one to five how glad they would be that their friend sent them this message and how uncomfortable they would feel receiving the message (1 = strongly disagree, 5 = strongly agree). Further, acceptance was assessed by participants’ qualitative responses. Specifically, those indicating a positive response to the vignette. Participants were additionally asked to provide a qualitative response to explain their answer to these questions. Finally, participants were asked, “How would you feel about receiving this message?”.

Statistical Analyses

All statistical analyses for hypotheses were created a priori. Descriptive statistics were used to analyze the participant demographics and ratings on the four closed-ended items. An ANOVA was used to assess the relationship between gender, vignette type, and participant response to each scaled question, with main effects of gender and vignette type included in the model. A two-way interaction effect for gender and vignette type was also included in the model. A bonferroni post-hoc analysis was used to examine the differences between the vignette types. Unfortunately, those participants identifying as “non-binary” were excluded from examination of gender differences due to the small group size.

A Delphi coding method (Dalkey, 1972; Holey et al., 2007; Jones & Hunter, 1995) was used to code qualitative responses. Research assistants coded responses to majority agreement. Research assistants were undergraduate and graduate students associated with the research lab conducting the study. They were previously trained by graduate student trainers using the specific coding method outlined. Individually, research assistants generated a theme list based on the responses of each question. Research assistants then discussed the independently generated themes. A consensus list was generated and themes were operationally defined. Then, research assistants independently coded each response per question. When appropriate, responses received multiple codes. Inter-rater reliability was 0.85 or greater.

Results

Quantitative Results

Most participants reported a likelihood (score of five or greater) that they would visit and contact their friend after reading the message (Fig. 2). Most participants also reported they would feel glad their friend contacted them, while few participants reported that they would feel uncomfortable receiving the message (Fig. 3).

Fig. 2.

Fig. 2

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Percentage of participant who reported likelihood to visit and contact their friend after receiving the hypothetical message. 1 = Not at all likely, 10 = Absolutely would

Fig. 3.

Fig. 3

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Percentage of participant who reported feeling glad and uncomfortable regarding receiving the hypothetical message

Likelihood to Visit

A general linear model for the likelihood to visit demonstrated did not demonstrate a significant two-way interaction (F(3,365) = 0.567, p = 0.637, η2 = 0.005), indicating that the relationship between vignette type and likelihood to visit the friend did not depend on the participant’s gender. An ANOVA to examine differences in responses between vignette type indicated there was a significant difference (F(3,365) = 3.01, p = 0.03, η2 = 0.024) A bonferroni post-hoc analysis revealed that respondents reported greater likelihood to visit the friend diagnosed with a TBI (M = 9.32 SD = 1.45) than a friend diagnosed with an eating disorder (M = 8.61, SD = 2.23) with no significant differences between other types. A t-test, including all vignette types, revealed a significant difference between male and female respondents [t(365) = 2.143, p = 0.03, η2 = 0.013], with females (M = 9.17, SD = 1.66) reporting greater likelihood to visit the friend compared to males (M = 8.76, SD = 2.08).

Likelihood to Contact

For likelihood to contact the friend, the two-way interaction term was not significant (F(3,365) = 1.78, p = 0.15, η2 = 0.015) indicating no significant relationship between vignette type and gender. There was also no significant differences between the vignettes [F(3,365) = 2.19, p = 0.089, η2 = 0.018]. There was a significant difference between male and female respondents (t(365) = 2.90, p = 0.003, η2 = 0.024). Female respondents (M = 9.53, SD = 1.22) indicated significantly greater likelihood to contact the friend compared to male respondents (M = 9.06, SD = 1.88).

Glad to Receive the Message

There was no significant two-way interaction by vignette type and gender (F(3,365) = 0.44, p = 0.727, η2 = 0.004)on whether participants reported feeling glad the friend contacted them. There was no significant differences between vignettes (F(3,365) = 1.30, p = 0.28, η2 = 0.01), but a significant difference by gender (t(365) = 2.45, p = 0.02, η2 = 0.02). Again, female respondents (M = 4.60, SD = 0.70) were significantly more likely to report that they would feel glad after receiving the message compared to male respondents (M = 4.40, SD = 0.89).

Uncomfortable with Message

There was also no significant interaction by vignette type and gender [F(3,365) = 0.707, p = 0.55, η2 = 0.006] when participants were asked if they would feel uncomfortable receiving this message. However, there was a significant difference in participant responses by vignette type [F(3,365 = 5.95, p = 0.001, η2 = 0.046], and a significant difference by gender [t(365) = -1.95, p = 0.049, η2 = 0.012]. Respondents reported feeling significantly more uncomfortable receiving a message from a friend diagnosed with an eating disorder (M = 2.17, SD = 1.25) compared to a friend diagnosed with cancer (M = 1.78, SD = 1.06), TBI (M = 1.55, SD = 0.79), and depression (M = 1.74, SD = 0.98). Female respondents (M = 1.72, SD = 1.02) also reported that they would feel more comfortable receiving this message from a friend compared to male respondents (M = 1.93, SD = 1.10).

Qualitative Results

Participants were asked to elaborate on their responses regarding whether they would be glad to receive the message and whether they would feel uncomfortable. The frequency of each theme per response, separated by vignette viewed, can be found in Table 2. Responses could be coded into multiple categories. Responses are written verbatim, including errors in syntax, punctuation, and spelling. The vignette type is identified in parentheses after each direct quotation.

Table 2.

Frequency of thematic qualitative codes by questions

Code Cancer (n = 89) TBI (n = 86) Depression (n = 96) ED (n = 92)
N % N % N % N %
I would be glad that my friend sent me this message under the circumstances. Please Explain
 Staying informed 16 18 11 12.8 16 15.7 11 11.7
 Importance of friendship 8 9 17 19.8 13 12.7 10 10.6
 Desire to support 9 10.1 0 0 11 10.8 9 9.6
 Empathy 5 5.6 0 0 6 5.9 2 2.1
 Unsure/don’t care 2 2.2 1 1.2 3 2.9 3 3.2
 Similar personal experience 2 2.2 0 0 4 3.9 1 1.1
It would make me uncomfortable to receive this message. Please explain
 Positive reaction to message 24 27 18 20.9 23 22.5 14 14.9
 Awkward 6 6.7 2 2.3 3 2.9 8 8.5
 Importance of being told 3 3.4 2 2.3 4 3.9 3 3.2
 Unsure/don’t care 2 2.2 2 2.3 1 1.0 4 4.3
 Personal information 0 0 0 0 0 0 1 1.1
How would you feel about receiving this message?
 Positive emotion 24 27 34 39.5 38 37.3 31 33
 Desire to support 13 14.6 14 16.3 20 19.6 14 14.9
 Feel sad/concerned 25 28.1 14 16.3 10 9.8 8 8.5
 Negative and positive emotion 15 16.9 7 8.1 12 11.8 8 8.5
 Negative about the message 4 4.5 4 4.7 3 2.9 15 16
 Importance of friendship 7 7.9 5 5.8 4 3.9 4 4.3
 Empathetic 3 3.4 1 1.2 4 3.9 2 2.1
 Overwhelmed 2 2.2 0 0 2 2.9 2 2.1
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Glad to Receive the Message

One-hundred thirty-seven participants commented on their response to “I would be glad that my friend sent me this message under the circumstances”. Interrater reliability per coded theme ranged from 0.85–0.98 (M = 0.91). Many respondents emphasized the importance of being informed of their friend’s situation. For example, one participant simply responded, “keeping me in the loop” (TBI) and another wrote, “I would want to know they are ok” (eating disorder). Other respondents emphasized the importance of being informed as a way of knowing how their friend was doing with one respondent writing, “I would want to know how they are doing” (cancer), or the importance of being informed as an explanation for their friend’s behavior; “If they are my friend I would still want to stay in contact with them and if they let me know what was going on i would probably assume they are just ignoring me or mad at me” (depression). These responses also included responses that emphasized the importance of their friend honestly telling them what is happening. For instance, one participant wrote, “They are being straight forward with me about the situation” (TBI). Finally, some participants that emphasized the importance of being informed also expressed feeling thankful their friend was comfortable enough to keep them informed. One response was, “I’m glad that they trust and want to keep in touch through hard times in their life” (cancer).

Several participants also provided responses that emphasized the importance of being a friend. For example, a few participants simply wrote “they are my friend.” One respondent wrote, “I care greatly about my friends!” (cancer). Others gave longer explanations, such as, “if they are a close friend, a car accident wouldnt change that. i would still want to be their friend” (TBI). Other responses suggested that the message would demonstrate the importance of their friendship, with one respondent writing, “i can see that she cares for our friendship” (TBI). While another response was, “He/She took the time out of their busy and sick life to still reach out and keep a friendship alive. That means so much” (cancer).

Several respondents also expressed a desire to support the friend after receiving the message. One respondent wrote, “i can be there as a support for my friend” (depression). While another participant gave a longer explanation, “I would want to be there to support them the best I could, and would be very glad they are getting the help they need” (depression). Fewer respondents expressed empathy for the friend and these responses were often combined with another category of response. For example, one participant expressed empathy, a desire to support the friend and the importance of being a good friend, “I think that it shows bravery to reach out to someone concerning such a difficult topic so I would want to embrace and accept this persons cry for help or friendship” (eating disorder).

Few respondents responded with a statement expressing a personal experience similar to the friend in the vignette. One participant responded, “Dealt with this before” (eating disorder), while another described a similar situation, “I have received a message similar to this in my lifetime” (cancer). Finally, some respondents indicated that they were either unsure about the message, would not care if they received a similar message, or that the message was none of their business. These answers were typically short, such as, “I would not know what to say back” (cancer), or “Not my business” (eating disorder). Notably, only male participants provided responses indicating either uncertainty or that the diagnosis was not the participant’s business. No other qualitative category had a clear gender divide.

Uncomfortable with the Message

One-hundred fifteen participants provided a statement after responding to the statement “It would make me uncomfortable to receive this message.” Interrater reliability per coded theme ranged from 0.87–0.99 (M = 0.94). The majority of participants provided a response expressing positive feelings regarding the message and were similar to those provided for the previous question. Many participants stated that they would not be uncomfortable with this message specifically stating, “It wouldn’t make me uncomfortable” (cancer), and another writing, “not at all” (cancer). Others questioned why someone would be uncomfortable with the message. One participant wrote “Why would someone reaching out to you make you uncomfortable?” (depression). Similar to the previous question, several participants emphasized the importance of friendship with one respondent simply writing, “That’s my friend” (TBI). One participant wrote, “THEY ARE MY FRIEND” (TBI). Another participant stated, “good friends don’t disappear when there’s trouble” (eating disorder). A few participants expressed feeling appreciative that a friend would trust them with this information. For instance, one participant stated, “happy to be confided in” (TBI) Similar to previous responses, a few participants emphasized the importance of being told what was happening with one participant writing, “It would be hard news to hear from a friend but I would want to know” (cancer).

Some respondents reported that it would feel awkward, upset, or strange to receive the message. One participant described potentially feeling uncomfortable and not knowing what to say writing, “I would feel uncomfortable since I would not know what to say or I do not have so much information about it” (cancer). Another participant wrote, “It’s kind of awkward” (depression), and another wrote, “weird to randomly receive message” (TBI). Finally, a few participants described feeling uncomfortable about their friend’s situation. One particular response was, “Finding out a friend has cancer is never comfortable” (cancer). A few respondents reported not knowing what to do or say back. One response was, “I am not good with emotions and find this to be a strain on how to appropriately respond” (eating disorder). Further, one participant stated, “not my business” (eating disorder). Finally, a respondent specifically described the message as personal, “it’s a little personal but its okay” (eating disorder).

Feelings About the Message

Two hundred eight-eight participants provided a qualitative response to the question, “How would you feel about receiving this message?” Interrater reliability per coded theme ranged from 0.89 to 0.97 (M = 0.94). The majority of participants expressed feeling happy (e.g., “glad” or “good”) or relieved their friend would reach out to them, trusted, thankful, grateful, and appreciative (e.g., “pleased”). For example, one respondent provided a representative response indicating positive feelings, “I would be happy to receive this message and comfortable enough to respond and visit” (TBI). Another respondent described that they would feel honored to receive this message stating, “I would feel honored that a friend wanted to reach out to me about something so personal. It might be awkward because I am not an expert on the subject but I would be willing to be a great friend” (eating disorder). Similarly another participant wrote, “I would feel special that my friend asked me to stay connected with him, that our friendship truly makes him happy” (depression).

Several participants also described a desire to support the friend, often along with either a positive emotion (e.g., glad) or a negative emotion (e.g., sad, scared). One response described both a desire to support the friend and personal emotions, “Obviously concerned and supportive of my friend. Glad that they know they can come to me with things, and eager to help them with whatever they’d need” (eating disorder). A response describing both a desire to support the friend and a negative emotion was, “I would feel very concerned and would try my best to see them and how they are doing since they someone there for them” (depression). Some responses simply described a desire to support the friend with one participant writing, “want to help them” (depression), and another writing, “call her, while grabbing my keys heading to see her” (TBI).

Some participants responded by expressing sadness or other negative emotions (e.g., “anxious, and shocked”) regarding hypothetically receiving the message. Some reported personal sadness, with one participant writing, “sad my friend has cancer” (cancer), and several other simply writing, “sad,” while other respondents wrote about concern for the friend. For instance, one participant wrote, “Concerned about their wellbeing” (eating disorder), and another wrote, “Feel bad for the friend” (cancer). Fewer participants reported that they would feel overwhelmed by the message. For instance, one respondent wrote, “I would feel like this would be a lot to take in as a teenager” (depression). The majority of these responses also included more than one feeling about the message and were coded in multiple categories, with one participant writing, “scared, nervous, eager, sad, surprised, shocked, worried” (eating disorder).

Several participants described a mix of negative and positive emotions. Most specifically described that they would feel sad and glad at the same time. For example, one participant wrote, “I would be sad that my friend has cancer, but glad that they told me their feelings” (cancer) and another wrote, “I’d feel sad that my friend was feeling this way, but I would be glad they felt they could confide in me and reached out” (depression). Another participant also described these feelings while also appreciative of the message writing, “It would be a bitter sweet feeling. It’s sad that they have a serious illness but I would be happy that they care enough to consider contacting me and telling me that they want me to stay involved in their life” (cancer). A fewer number of respondents described that they would feel scared or worried while also feeling happy, with one participant writing, “i would be happy but very scared” (cancer).

Some participants described negative feelings or indifference regarding the message. Specifically, one participant wrote, “uncomfortable” (TBI), while another wrote, “seeking attention” (depression). One participant described the message as a hassle [e.g., “it’s a hassle” (eating disorder)], a few described indifference [e.g., “indifferent” (depression) or “no feeling” (eating disorder)], and one wrote, “I wouldn’t know how to feel” (eating disorder).

Similar to the previous two qualitative questions, a limited number of participants emphasized the importance of friendship and being supportive of a friend, these responses were often included in a variety of other qualitative answers expressing positive emotions, sadness, or support. One participant described positive emotions surrounding the message and emphasizing friendship, writing, “I would love receiving this message. I would absolutely visit a friend in the hospital. Friendship is very important to me” (cancer) A few participants also provided statements specifically describing empathy, compassion, or sympathy. The majority of these responses were within the context of another type of response. One response was, “I would feel their pain and hurt for this problem because I have been there before and know how it is to feel like that” (depression).

Discussion

The present study investigated young adults’ reactions to a short hypothetical chronic illness disclosure message from a friend while in their junior year of high school. The initial results demonstrate overwhelming willingness, acceptance, and appreciation of a short message informing a friend of recent chronic illness. Specifically, participants were accepting of and responded positively to the message, supporting the first hypothesis. Across the four vignette types, participants reported a high likelihood to visit and contact their friend, feeling glad to hear from their friend, and feeling comfortable receiving the message. The second hypothesis, which stated that participants would be more likely to report feeling uncomfortable when receiving a hypothetical mental health diagnosis message, was only partially supported. Overall, there was no significant difference between the depression, TBI, and cancer vignettes; however, participants reported greater discomfort with the eating disorder vignette. Despite this significant difference, it is worth noting that participants responding to the eating disorder message still overwhelming reported a high likelihood to visit and contact their friend, and they would be glad their friend contacted them. Participants’ qualitative responses also reflected a high degree acceptability of the message. Participants reported positive emotions regarding the message, a desire to support the hypothetical friend, the importance of staying informed of the friend’s situation, and the importance of being a good friend, with many fewer participants reporting not wanting to know about the recent diagnosis or receive such a message.

This high degree of acceptability across vignette types is especially important as there is ample evidence that peer social support during late childhood and adolescence can have a positive effect on quality of life (e.g., Taylor et al., 2008; Papadopoulos & Papkonstantinou, 2020; Reuger et al., 2016) and positive health behaviors, especially in the chronic illness population (Gao et al., 2022; La Greca et al., 2002). Additionally, adolescents with various chronic illnesses report that life is better when engaged with friends despite stressors associated with their diagnosis (Taylor et al., 2008).

When examining gender differences, females were generally more likely to report a desire to visit and contact the friend, and they felt glad to hear from the friend after receiving the message. However, gender differences were quite modest with small effect sizes and with a high degree of positive reaction from males as well. Therefore, these differences appear to be of limited clinical significance. Thus, the results suggest the illness type appears to be more important than the friend’s gender. However, in the qualitative responses, though only few participants reported that they would not know how to respond to their friend, all these participants were male. There was no effect of gender on the vignette type. While considering the recipient’s gender may be less important, male friends may need more direction in how the friend would like them to respond.

Respondents were more likely to report feeling uncomfortable receiving a message from a friend recently diagnosed with an eating disorder compared to the other diagnoses, including depression. Although there is significant perceived stigmatization of mental health disorders amongst peers (Elkington et al., 2012), the present study suggests the need for further exploration on the potentially greater level of stigmatization of eating disorders compared to depression. Jorm and colleagues (2005) demonstrated an increase in public belief that mental health illness, such as depression and schizophrenia, have genetic causes, rather than being due to a “weakness of character over the last few decades.” However, the general public’s understanding of eating disorders remains poor when compared to more common mental disorders like depression (Brelet et al., 2021; Mond, 2014). An increased public understanding of the biological causes of depression may allow individuals to characterize depression as more like physical illnesses, and less like eating disorders.

Often, the prospect of disclosing a chronic illness can be scary and result in concern or worry about the impact disclosure will have on a relationship (e.g., Kirk & Hinton, 2019; Sannon et al., 2019; Shiu et al., 2003). Such fear may result in individuals delaying disclosure, which subsequently delays the availability of specific social support regarding their chronic illness diagnosis. However, the results of the present study add to the growing body of literature which demonstrates that disclosure is positively received by community members (Austin et al., 2016; Shiu et al., 2003), particularly when individuals have a safe space for disclosure (e.g., Forgeron et al., 2015). Having an initial standardized message available to individuals with chronic illness may potentially lessen anxiety regarding disclosure. With the help of a psychologist or other health professionals, individuals may even tailor a standardized message to reflect their own preferred method of communication, style of speech and communication, and specific illness-related symptoms and/or concerns. Additional, the positive impact of the use of social media and other digital communications to remain connected with others throughout the COVID-19 pandemic (e.g., Suwinvattichaiporn & Turner, 2020; Samji et al., 2022) further supports the use of digitally-mediated communications. A written standardized message lends well to this type of communication.

Respondents’ initial positive reaction suggests the utility of a short, standardized message to promote communication and peer support in an adolescent chronic illness population. Additionally, this message is a low burden intervention and more cost-effective than previous interventions used to promote social support in this population (e.g., Lau et al., 2020; Moola et al., 2014). Despite evidence-based interventions which are often effective at addressing mental health care needs, many individuals with recently diagnosed health conditions continue to have unmet mental health concerns (Delamater et al., 2017). Thus, it is important to increase access to evidence-based interventions for individuals with mental and/or physical health conditions, in the current health care system.

Further, there is growing support for use of hospital support staff or “lay healthcare workers” who receive training and supervision regarding specific psychological interventions for common mental health disorders (Javadi et al., 2017; Shahmalak et al., 2019). A clinical psychologist has appropriate training and expertise to serve as a leader to enact changes within a healthcare system and guide lay healthcare workers in providing effective interventions, such as tailoring a message similar to the suggested message presented here, in order to best serve patients’ individual need for improved communication and peer support. These staff could be trained to adapt and tailor our proposed message to each individual, in order to maximize awareness of the specific illness and garner support from peers. Notably, it is important to note that disclosure of a physical or mental illness may not necessarily be universally positive (e.g., if there associated safety concerns related to disclosure). Therefore, inclusion of a psychologist may be particularly important in helping individuals considering disclosure also consider the potential positive and negative impact of disclosure.

It is important to acknowledge, the results of the present study suggest eating disorder disclosure may require a more nuanced approach due to the potentially higher peer discomfort with this diagnosis. Individuals may benefit from greater involvement of trained mental health providers, such as psychologists, when disclosing an eating disorder to peers. Further, it is notable that early disclosure likely is not universally positive across contexts and all chronic physical and mental illnesses. When working with an individuals, particularly pertaining to disclosure, psychologists can play a particularly important role in understanding the context and nuance of different chronic illnesses. This may be particularly important when working with individuals diagnosed with more stigmatized illnesses (e.g., eating disorders; Brelet et al., 2021). The current study aims to add to the disclosure literature more broadly and provide support for disclosure to friends, while also acknowledging the importance of nuance and individual experiences.

The results of the present study should be considered in the context of known limitations. The instructions asked respondents to answer as though they received this message when they were 16. Some participants were as old as 24 and may have had difficulty responding as they would have 8 years earlier. Given the positive results here, replication with an adolescent sample would be important. Further, participants may have provided socially desirable responses rather than their true reaction to the disclosure. Although, the anonymity of the survey could have reduced this effect, future research should explore ways to minimize concerns regarding social desirability. Further, complete data on participants' personal experiences with friends with chronic physical or mental illnesses or personal experiences, is unknown. Personal experience could alter responses. Additionally, a clear definition of friendship was not provided to participants. It is possible, participants had differing views of responsibilities and expectations of friendship; therefore, this may be captured in their responses. Finally, because this was a hypothetical message from any friend, the results are not completely representative of different types of relationships in adolescents. The nature of the relationship between two friends could have a high impact on a healthy friend’s response to recent diagnosis disclosure. Future research should investigate the use of this message with different relationship types in adolescence (e.g., acquaintance, close friend, or romantic relationship).

This study was the first step in examining the potential use of a standardized message to promote social support in an adolescent population recently diagnosed with a chronic illness. The overwhelmingly positive response to the standardized message suggests the utility of such a message to garner social support; however, the use of this message for diagnoses that are potentially more stigmatized (e.g., eating disorder, substance use disorders) should be investigated further. Additionally, because of the hypothetical nature of the study, future research should investigate the use of this message in an adolescent chronic illness population with a greater range in ages and with clinical populations.

Authors’ Contribution

All authors contributed to the study design, study conception, and manuscript preparation. Data collection and data analysis were performed by ECI. The first draft of the manuscript was written by ECI and JEA and all authors contributed to editing various manuscript drafts. All authors read and approved the final manuscript.

Funding

This study did not receive funding.

Data Availability

Raw data is available upon request to corresponding author.

Declarations

Conflicts of interest

Authors Eva C. Igler, Jillian E. Austin, Ellen K. D. Sejkora, and W. Hobart Davies declare that they have no conflict of interest.

Ethical Approval

The current study procedures followed ethical standards and were approved by the Institutional Review Board at a large Midwestern University in the United States.

Human and Animal Rights

Procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 and 2008.

Consent to Participate

Study participants completed informed consent and confirmed they were at least 18-years-old upon visiting the survey webpage.

Consent for Publications

All authors consent to publication of the current manuscript and data if the manuscript is accepted for publication.

Footnotes

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Data Availability Statement

Raw data is available upon request to corresponding author.

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