Evaluating a Pilot Culturally Sensitive Psychosocial Intervention on Posttraumatic Growth for Chinese American Breast Cancer Survivors

Abstract

This study investigated the potential benefit of a pilot culturally sensitive group support intervention, named Joy Luck Academy (JLA), in fostering posttraumatic growth among Chinese American breast cancer survivors. Eighty-six Chinese American breast cancer survivors participated in an eight-week single-arm pre-/post-test trial of an intervention program, which included educational lectures and peer mentor support. The JLA participants were compared with an independent sample of 109 Chinese American breast cancer survivors who went through routine care. Both groups completed baseline and eight-week follow-up assessments of the five facets of posttraumatic growth (meaningful interpersonal relationships, finding new possibilities in life, personal strength, appreciation of life, and spirituality). From baseline to follow-up, the JLA participants displayed significant improvements in the total score of posttraumatic growth (d = 0.44, 95% CI: 3.64 to 11.17), meaningful interpersonal relationships (d = 0.44, 95% CI: 1.18 to 3.81), appreciation of life (d = 0.33, 95% CI: 0.17 to 1.60), finding new possibilities in life (d = 0.40, 95% CI: 0.92 to 3.06), and personal strength (d = 0.36, 95% CI: 0.54 to 2.23). In contrast, the routine care participants showed no significant change in any of these outcome variables (all p > .05, d < 0.2). The findings suggest the potential benefit of a culturally sensitive group support intervention in facilitating posttraumatic growth for Chinese American breast cancer survivors, indicating the need for a randomized controlled trial. The educational lectures and peer mentor support may be adapted to tailor the needs of other ethnic minority cancer patients.

Introduction

Asian immigrant population in the United States has been growing rapidly for the past decades, and Chinese immigrants represent the largest subgroup of this population.¹ Breast cancer is the cancer type with the fastest growing incidence among Asian American women.^2,3 However, few culturally tailored intervention programs have been done to facilitate psychosocial adjustment among Chinese American breast cancer survivors. The present study aimed to examine whether a pilot group support intervention, which featured educational lectures and peer mentor support, would be associated with improvement in posttraumatic growth among Chinese American breast cancer survivors.

Research has demonstrated the essential role of social support in facilitating psychological well-being among breast cancer survivors.^4,5 According to the stress-buffering hypothesis,⁶ the perception that other people are here to support and help can influence the stress appraisal process, making individuals perceive the stressors as less harmful and increasing self-efficacy in stress coping. However, Chinese American breast cancer survivors face cultural obstacles that may limit their opportunities to obtain social support. Living in a foreign country far from their hometown, Chinese American breast cancer survivors find it hard to obtain emotional support from their close family members.⁷ Because Chinese culture values emotional suppression⁸ and emphasizes women’s roles as caregivers rather than dependents,⁹ Chinese American breast cancer survivors tend to conceal their cancer diagnosis and inhibit the distressing feelings for fear of burdening their family members.¹⁰ Cultural beliefs about cancer may also impede support seeking. Because cancer is perceived as a consequence of immoral behaviors in Chinese culture,¹¹ Chinese American breast cancer survivors tend to feel ashamed to share their experiences with their friends and colleagues.⁷ These stigmatized beliefs can also be internalized by Chinese American breast cancer survivors, which may lead to diminished self-value and loss of hope for the future.¹¹ In addition, the language barrier makes it difficult for Chinese American breast cancer survivors to communicate with their healthcare providers about their diagnosis and treatment options.¹² Indeed, research has indicated that Chinese American breast cancer survivors lack knowledge about the importance of cancer screening and early detection.¹³ They are also confused about the risk factors of breast cancer, but have little knowledge on where to obtain accurate information.¹³

Given the many challenges in accessing social support, culturally sensitive group support interventions may be beneficial to Chinese American breast cancer survivors to cope with the stress and improve psychological well-being. We developed a pilot culturally tailored group support intervention program for this minority population, called the Joy Luck Academy (JLA). Based on Chinese American breast cancer survivors’ unmet needs for informational and emotional support, the JLA featured two components: weekly educational lectures and peer mentor support. It targeted Chinese American breast cancer survivors who completed primary treatment within the past three years, to facilitate social and psychological adjustment during the transition from ‘patient’ to ‘survivor’.¹⁴

For this pilot study, we aimed to explore the potential benefit of JLA in facilitating posttraumatic growth among Chinese American breast cancer survivors. We focused on posttraumatic growth as the outcome because research has documented its association with positive psychological adjustment among cancer survivors (for a review and a meta-analysis, see^15,16) and its close relationship with social support.^17,18 Being diagnosed with and treated for breast cancer can be a challenging and traumatic life event.¹⁹ The breast cancer experience can be detrimental to an individual’s psychological well-being and undermine prior assumptions of invulnerability and control.^20,21 However, posttraumatic growth,²² defined as the positive psychological changes resulting from coping with trauma, has been observed among breast cancer survivors.²³ These positive changes include meaningful relationships with others, finding new possibilities in life, a sense of personal strength, appreciation of life, and deeper spirituality.^22,24

Social support is an important factor in promoting posttraumatic growth after breast cancer diagnosis.^17,18 A supportive environment created by family and friends may serve as a harbor for breast cancer survivors to disclose their innermost thoughts and feelings about their cancer experience. According to Horowitz’s formulation of stress-response syndromes,²⁵ the emotional disclosure processes facilitate cognitive integration of the traumatic cancer experiences, including processes of assimilation (i.e., reappraising the traumatic event to fit one’s preexisting schemas) and accommodation (i.e., changing preexisting schemas to be coherent with the traumatic experience). Through assimilation and accommodation processes, breast cancer survivors can reappraise the cancer experience in personally meaningful ways, restore the meanings about the self and life, which are often negatively affected by the cancer experience, and hence rebuild their confidence for the future.²⁶ In addition to support from family and friends, association with peer cancer survivors may be particularly helpful in facilitating posttraumatic growth. Previous studies have indicated that Asian breast cancer survivors are more likely to disclose their feelings to peers who share their experiences compared to strangers or healthy family members.²⁷ Being accompanied by people who share similar cancer experiences and distressing feelings creates a sense of belonging that allows breast cancer survivors to feel more secure and comfortable in disclosing their deepest fears.¹⁷ Peer interactions between survivors may also facilitate the peer-learning process, which can help individuals alter their perspectives on cancer and life, and to find new possibilities for the future.^28,29

Although previous studies have demonstrated the effectiveness of group-based psychosocial interventions in facilitating posttraumatic growth among non-Hispanic white breast cancer survivors,^30–32 empirical evidence is lacking for Asian American breast cancer survivors. The JLA intervention program involves 8 cohorts of Chinese American breast cancer survivors. Our previous work, based on data of the first cohort of participants (n = 14), has demonstrated the feasibility of the JLA program.³³ During the first two cohorts, we revised the intervention design regarding the curriculum of the educational lectures, group activities and duration of the intervention sessions, based on participants’ feedbacks. The intervention design was fixed from Cohort 3 to 8. The present study was based on data of Cohort 3 to 8 with a more standardized intervention design and a larger sample. In addition, we compared the JLA participants with an independent sample of Chinese American breast cancer survivors who received routine care (i.e., the type of health care a patient would normally receive from the hospital or community if not involved in the JLA intervention). We hypothesized that from baseline to 8-week follow-up, participants in the JLA group would show greater improvement in posttraumatic growth compared with participants in the routine care group.

In order to reach and work with this minority population, we adopted the community-based participatory research (CBPR) approach,³⁴ which emphasizes the active participation of communities, organizational representatives, and researchers throughout the research process. We collaborated closely with Herald Cancer Association (HCA), a non-profit Chinese community organization experienced in providing cancer education, community services, and facilitating support groups for Chinese American breast cancer survivors. The HCA staff members have a better understanding of the psychosocial needs and cultural sensitivity of the studied population, and actively participated in participant recruitment, the intervention design, the development of study materials, and the intervention implementation. In light of the established trust between the participants and HCA, the HCA staff members took a leading role in facilitating the activities of the JLA intervention program. Throughout the intervention program, weekly project meetings were held between the HCA and the research team to discuss ways to address participants’ needs, the implementation and management of the intervention program.

Methods

Participants

The JLA participants and the routine care participants were recruited separately in local communities in Southern California, New York and Dallas metropolitan areas through community networks. The JLA participants included in the present study were recruited from July 2011 to July 2014, with two cohorts conducted each year. The participants in the routine care group were recruited from July 2015 to March 2016. Potential participants were introduced to the study at cultural events and community support groups. The inclusion criteria for the JLA participants included: (1) diagnosed with breast cancer; (2) comfortable reading and speaking in Chinese (Mandarin or Cantonese); and (3) completed primary treatment (surgery, chemotherapy and radiation therapy) within the past three years. We specified the time since completing treatment to be less than 3 years because the JLA was particularly designed to facilitate survivors’ early adaptation after treatment. The routine care participants were originally recruited for an independent study that investigated psychological well-being among Chinese American breast cancer survivors. For routine care participants, the inclusion criteria were the same as the JLA participants except that the time since completing primary treatment was not restricted to the past three years. A total of 86 participants were recruited to the JLA group and 109 participants were recruited to the routine care group. The present study received approval from relevant institutional review boards. Informed consent was obtained from all individual participants included in the study.

Procedure and Materials

Both groups completed a baseline questionnaire package, which included demographic and clinical information, and assessments of posttraumatic growth. The JLA participants went through the eight-week intervention and completed the follow-up assessment of posttraumatic growth immediately after the intervention, i.e., eight weeks after the baseline assessment. The routine care participants completed the follow-up assessment of posttraumatic growth eight weeks after the baseline assessment. Thus, the time interval between baseline and the follow-up assessment was the same (i.e., eight weeks) for both groups. Participants in the routine care group were not exposed to any part of the JLA intervention, and were free to participate in any type of health care they would normally receive from their hospitals or communities.

The JLA program consisted of seven weekly group intervention sessions and one graduation ceremony in the eighth week. Each weekly session featured two components: educational lectures and peer mentor support. The educational lectures aimed to provide informational and emotional support by sharing knowledge about post-treatment self-care and stress coping, guiding participants as a group to re-evaluate their cancer experience in personally meaningful ways and to develop new goals for the future. The peer mentor support component provided opportunities for Chinese American breast cancer survivors to connect with their peer survivors, who share a similar cultural background and cancer experiences, to disclose their inner feelings about their disease and life, and to get mentorship from ‘veteran’ survivors, who had achieved good adjustment by self-report.

Educational Lectures.

Each weekly lecture was about two hours long, with a 15-minute relaxing exercise in between to reduce fatigue. Each lecture covered one or more of the following topics that target Chinese American breast cancer survivors’ needs for informational and emotional support in achieving successful adjustment, including a) basic knowledge about breast cancer and risk factors; b) understanding a pathology report; c) the guidelines and importance of breast cancer follow-up visits and examinations; d) self-care and managing post-treatment side effects; e) nutrition and exercise; f) Chinese traditional medicine as a supplement to cancer treatment; g) personal care and dressing tips after treatment, including usage of prosthesis; h) developing positive perspectives about cancer and building self-value; i) communication strategies with families and healthcare professionals, and j) emotional regulation and stress coping strategies. The lectures were prepared and delivered by professionals from various disciplines, including an oncologist, a Chinese traditional medicine doctor, a clinical psychologist, a physical therapist, and a dietician. Following each lecture, a Q&A session was held to address participants’ questions. In the eighth week, a graduation ceremony was held with a celebratory luncheon for mentors and participants to share their achievements throughout the JLA program. A graduation certificate was conferred to each participant to honor their completion of the program.

Peer Mentor Support.

Peer mentor support was implemented by assigning a mentor to each participant using a matching system based on cancer stage, treatment history, preferred spoken language (Mandarin or Cantonese) and origin of birth. The mentor to mentee ratio ranged approximately from 1:4 to 1:2. Mentors were recruited based on the following criteria: a) Chinese speaking breast cancer survivors; b) completed primary treatment; c) in good self-reported health condition and adjustment, and d) available and willing to commit to mentoring the participants. Each mentor went through a 3-hour training session to discuss their responsibilities, go over lecture materials, and train their skills of leading group discussions. Peer mentor support was implemented in two ways. First, a mentor-facilitated small group discussion was held following each lecture to allow participants to share their experiences and feelings. Second, mentors called participants every week to attend to participants’ social and emotional needs, share their own stress coping experience, and encourage participants to maintain active engagement in the program.

Several strategies were adopted to facilitate cultural sensitivity of the intervention: First, the entire lecture was delivered in Chinese, and mentors and mentees were matched based on cancer stage, treatment history, preferred spoken language (Mandarin or Cantonese) and origin of birth. Second, the lecture contents were tailored in accordance to Chinese culture and to target Chinese American breast cancer survivors’ unmet needs for informational support. Specifically, advice about nutrition was provided in line with Chinese eating and cooking habits; basic training was also offered about exercises that are popular in Chinese culture, such as acupressure and Tai Chi; moreover, considering participants’ unfamiliarity of the US healthcare system and limited English language abilities,¹⁰ training was given for effective communications with physicians and understanding a pathology report. Third, in line with Chinese cultural value of emotional restraint in public,⁸ small group discussions and one-on-one phone meetings were held between mentors and mentees in addition to the big group discussions, so participants had an opportunity to receive advice on personal issues, and to share feelings that they were not comfortable sharing in the big group.

Measure of Posttraumatic Growth

Posttraumatic growth was assessed using the 21-item Posttraumatic Growth Inventory (PTGI).³⁵ The scale contains five subscales that measure the five facets of posttraumatic growth: meaningful interpersonal relationships, finding new possibilities in life, a sense of personal strength, spirituality, and appreciation of life. Participants were asked to indicate the degree to which they experienced the change described in each item in relation to cancer experience on a 6-point scale from 0 (I did not experience this change) to 5 (I experienced this change to a very great degree). The Chinese version of the scale indicated good reliability and validity in previous studies for other groups of Chinese breast cancer survivors.³⁶ In the present study, the internal reliabilities were adequate for the whole PTGI (Cronbach’s α = .96) and the five subscales (Cronbach’s α = .70 - .99).

Analysis Strategy

First, independent samples’ t-tests and chi-square tests were performed to test baseline equivalence between the two groups in terms of demographic and clinical characteristics. Second, bivariate correlations were conducted between sample characteristics and outcome variables (the PTGI total score and subscale scores) to identify potential covariates. Main hypotheses were tested using Hierarchical Linear Modeling (HLM) in SAS 9.4 software (SAS Institute, Cary, NC). Independent models were estimated for PTGI total score and the five subscale scores. Each model included time (baseline vs. follow-up), group (JLA group vs. routine care group) and their interaction term, controlling for relevant covariates. A significant group × time interaction would suggest that the change in posttraumatic growth during the 8-week period significantly differed between the JLA group and the routine care group. For models with a significant group × time interaction, we conducted planned contrasts tests to (a) examine the change in the outcome variables from baseline to follow-up for each group; and (b) examine group differences at follow-up assessment, controlling for the baseline level. Missing data were handled using residual maximum likelihood (REML) estimation.

Results

Demographics and clinical characteristics of the two groups are presented in Table 1. For the JLA group, all 86 participants completed baseline assessments, and 76 participants completed the intervention and the follow-up assessment (retention rate = 88.4%). For the routine care group, all 109 participants completed the baseline assessment, and 100 participants completed the follow-up assessment (retention rate = 91.7%).

Table 1.

Demographic and clinical characteristics by group

Variables	JLA Group (n = 86)		Routine Care Group (n =109)		p
	frequency	%	frequency	%
Age					.03
Mean (SD)	55.31 (8.47)		58.43 (8.92)
Marital status					.20
Married	39	57.4	80	74.1
Never married	13	19.1	10	9.3
Widowed	5	7.4	5	4.6
Separated	2	2.9	3	2.8
Divorced	9	13.2	10	9.3
Educational level					.03
Below high school	9	10.5	12	11.0
Some or complete high school	25	29.1	28	25.7
Some or complete college	28	32.6	52	47.7
Graduate school	3	3.5	16	14.7
Treatment completed
Surgery	61	70.9	89	81.7	.28
Radiation	33	38.4	63	57.8	.97
Chemo	43	50.0	68	62.4	.21
Cancer stage					.11
0	3	3.5	13	11.9
1	22	25.6	31	28.4
2	24	27.9	46	42.2
3	17	19.8	18	16.5
4	1	1.2	0	0.0
Time since diagnosis (in months)					<.001
Mean (SD)	16.79 (18.90)		82.18 (67.05)

Note. Participants may complete more than one treatment type. Percentages may not add up to 100% because of missing data.

Baseline Equivalence and Correlations

Descriptive statistics of posttraumatic growth at each assessment session are presented in Table 2. At baseline, the two groups did not differ significantly on the PTGI total score or any subscale score (all p >.10). Among all the assessed demographic and clinical characteristics, the two groups only differed significantly in age, time since cancer diagnosis and educational level. Specifically, compared with the routine care participants, the JLA participants were significantly younger, t = 2.25, p = .03, had shorter time since diagnosis (in months), t = 9.23, p < .001, and had lower educational level, t = 2.15, p = .03. Among all the sample characteristics, only education was significantly associated with the outcome variable, specifically, appreciation of life (r = .17, p = .03). Although age and time since diagnosis were not significantly related to the PTGI total score or any subscale score (all p > .10), we chose to be conservative and included age, time since diagnosis and educational level as covariates for all the outcome variables in the subsequent analyses. There were no significant group differences in other sociodemographic and clinical characteristics (all p > .05).

Table 2.

Means and standard errors (SEs) of outcome variables

Outcome Variable	JLA group				Routine Care group
	Baseline		Follow-up		Baseline		Follow-up
	M	(SE)	M	(SE)	M	(SE)	M	(SE)
PTGI total score	69.96	(2.63)	77.37	(2.65)	68.23	(2.20)	68.34	(2.23)
Interpersonal relationship	25.29	(0.84)	27.78	(0.84)	24.63	(0.70)	24.15	(0.71)
New possibilities	14.82	(0.74)	16.81	(0.74)	14.64	(0.62)	15.22	(0.63)
Personal strength	13.14	(0.58)	14.53	(0.59)	13.36	(0.49)	13.52	(0.50)
Spirituality	6.98	(0.38)	7.65	(0.38)	6.13	(0.32)	6.19	(0.32)
Appreciation of life	9.62	(0.42)	10.51	(0.43)	9.45	(0.35)	9.25	(0.36)

Note. PTGI: Posttraumatic Growth Inventory.

Hierarchical Linear Modeling

There was a significant time × group interaction for the PTGI total score, F = 8.39, p = .004; the score of meaningful interpersonal relationship, F = 11.51, p = .001; personal strength, F = 4.69, p = .032; appreciation of life; F = 5.07, p = .026; and a marginal time × group interaction effect for the score of finding new possibilities in life, F = 3.93, p = .050. There was no significant interaction between time and group for the score of spirituality, F = 3.71, p = .056.

We then conducted planned contrasts tests to decompose the significant interaction effects on PTGI total score and the four subscale scores.

First, we examined changes in the outcome measures from baseline to follow-up in two groups, respectively. As indicated in Figure 1, for participants in the JLA group, there was a significant improvement in the PTGI total score, M_difference = 7.41, t = 3.89, p < .001, 95% CI [3.64, 11.17], Cohen’s d = 0.44, and all the four subscale scores, including the score of interpersonal relationship, M_difference = 2.49, t = 3.76, p < .001, 95% CI [1.18, 3.81], Cohen’s d = 0.44; the score of finding new possibilities in life, M_difference = 1.99, t = 3.68, p < .001, 95% CI [0.92, 3.06], Cohen’s d = 0.40; the score of personal strength, M_difference = 1.39, t = 3.25, p = .001, 95% CI [0.54, 2.23], Cohen’s d = 0.36; and the score of appreciation of life, M_difference = 0.88, t = 2.43, p = .016, 95% CI [0.17, 1.60], Cohen’s d = 0.33. In contrast, participants in the routine care group showed no significant change from baseline to follow-up in any of the outcome measures above, including PTGI total score, M_difference = 0.11, t = 0.07, p = .950, 95% CI [−3.15, 3.37], Cohen’s d = 0.01; the score of interpersonal relationship, M_difference = −0.48, t = −0.84, p = .402, 95% CI [−1.62, 0.65], Cohen’s d = 0.09; the score of finding new possibilities in life, M_difference = 0.57, t = 1.22, p = .224, 95% CI [−0.35, 1.50], Cohen’s d = 0.15; the score of personal strength, M_difference = 0.16, t = 0.45, p = .656, 95% CI [−0.57, 0.89], Cohen’s d = 0.05; and the score of appreciation of life, M_difference = 0.20, t = −0.63, p = .530, 95% CI [−0.82, 0.42], Cohen’s d = 0.06.

Figure 1.

Least square means for the PTGI total score and the five subscale scores for the JLA group and the routine care group, adjusted for age, education and time since cancer diagnosis. PTGI: Posttraumatic Growth Inventory.

Next, we compared group differences in the outcome measures at follow-up session, controlling for baseline level. At 8-week follow-up, the JLA participants were significantly higher than the routine care participants in the PTGI total score, M_difference = 9.04, t = 2.45, p = .015, 95% CI [1.75, 16.32], Cohen’s d = 0.40; the score of meaningful interpersonal relationship, M_difference = 3.63, t = 3.10, p = .002, 95% CI [1.32, 5.94], Cohen’s d = 0.50; and the score of appreciation of life, M_difference = 1.26, t = 2.12, p = .036, 95% CI [0.08, 2.43], Cohen’s d = 0.34. There were no significant group differences at follow-up in the score of finding new possibilities in life, M_difference = 1.59, t = 1.54, p = .126, 95% CI [−0.45, 3.64], Cohen’s d = 0.25, or the score of personal strength, M_difference = 1.00, t = 1.23, p = .222, 95% CI [−0.61, 2.62], Cohen’s d = 0.20.

Discussion

The present study aimed to evaluate the potential benefit of a culturally sensitive group support intervention, JLA, in fostering posttraumatic growth among Chinese American breast cancer survivors. We found that compared with the routine care group, participants in the JLA group showed greater improvements in PTGI total score, and four of the five facets of posttraumatic growth, including meaningful interpersonal relationships, appreciation of life, personal strength and finding new possibilities in life during the eight-week study period.

Previous research on group-based psychosocial interventions targeting posttraumatic growth among cancer survivors was primarily focused on non-Hispanic whites, and have showed small- to medium-level of effects in facilitating posttraumatic growth.^30–32 For example, in an 8-session building resilience group intervention, breast cancer survivors in the intervention group showed moderate level of improvement in posttraumatic growth from baseline to 6-months follow-up (Cohen’s d = 0.32). In another study which evaluated a positive psychotherapy group intervention program, women with diverse types of cancer who participated in the intervention showed medium effects of improvement in posttraumatic growth from baseline to post-intervention (${\text{η}}_{\text{p}}^2=0.08$). The magnitude of the within-person changes in posttraumatic growth observed in the present study was comparable to the previous research: We found that Chinese American breast cancer survivors in the JLA group showed small- to medium-levels of effects in the improvement in PTGI total score and four of the five facets of posttraumatic growth (Cohen’s d = 0.33 to 0.44); in contrast, participants in the routine care group showed no significant change in any of the outcome measure. Moreover, at 8-week follow-up, we observed small- to medium-level of effect sizes for the group differences in the PTGI total score, the score of meaningful interpersonal relationships and appreciation of life (Cohen’s d = 0.34 to 0.50), with the JLA participants showing significantly higher scores in these outcome measures than the routine care participants. These findings suggest the potential benefit of a culturally sensitive group intervention, which combines psychoeducation and peer mentor support, in facilitating posttraumatic growth among Chinese American breast cancer survivors.

There are two plausible explanations for the observed greater improvement in posttraumatic growth among JLA participants compared with the routine care participants. First, the JLA intervention may well meet Chinese American breast cancer survivors’ desire for emotional disclosure and social support. Due to language and cultural barriers, Chinese American breast cancer survivors have difficulties expanding their social networks and seeking help from mental health professionals.^3,37,38 They also tend to suppress their thoughts and feelings from their social networks to avoid disrupting relationship harmony.³⁷ Even when talking with family and friends, Chinese breast cancer survivors may experience unsupportive and avoidant responses,³⁹ since it may be difficult for healthy family members to stand in the survivors’ shoes to adequately empathize with the distressing feelings related to cancer.⁴⁰ The peer mentor support in the JLA program provided an opportunity for Chinese American breast cancer survivors to connect with their peer survivors, who share a similar cultural background, cancer experiences, and the distressing feelings, and thus offered a safe and accepting environment for participants to disclose their innermost fear and sadness. This emotional disclosure process can also help cancer survivors recognize their vulnerability and fear surrounding cancer, which may be deep-seated, and thus can increase their willingness to seek help and increase their desire for meaningful relationships.³⁵

Second, the JLA program offered informational support that may be potentially beneficial in fostering survivors’ confidence in building personal strength, discovering new possibilities in life, and promoting appreciation of life. Specifically, the educational lectures shared useful skills to help survivors build confidence in addressing the challenges in life with cancer, such as positive communication with their families and colleagues, emotional regulation, and effectively seeking healthcare support. The lectures also provided training in various life domains, which aimed to help participants rebuild personal strength and find new opportunities in life. This training included (a) building hope for the future through reappraising their cancer experience as an opportunity for growth, and (b) improving self-image and reducing self-stigma by teaching personal care skills, dressing tips, and appropriate usage of prosthesis. Moreover, the peer mentor support also allowed participants to learn from ‘veteran’ well-adjusted survivors about the ability to thrive after cancer treatment, and help them build personal strength to cope with the stressors in life.

Considering the social and cultural challenges that Chinese American breast cancer survivors face in adjustment after cancer treatment, the present pilot study provides valuable evidence that informs the potential benefit of a culturally tailored group support intervention in facilitating posttraumatic growth among Chinese American breast cancer survivors. The cultural sensitivity of this program has the potential to be applied to healthcare and research on other minority cancer survivor populations: First, interacting with peer cancer survivors who share similar cultural backgrounds and cancer experiences may help increase minority cancer survivors’ engagement in the intervention. Second, exposure to well-adjusted mentors also provided cancer survivors with role models who were able to overcome obstacles and adjust to life after cancer, which helped survivors build hope for the future. Future research may be directed to tailor the program design to the specific psychosocial needs of other ethnic minority cancer patients. Lastly, the findings also have implications on clinical practice and research about posttraumatic growth. We observed that the five facets of posttraumatic growth differed in the magnitude of change from baseline to follow-up, which suggests that the five facets may represent distinct constructs. The distinctiveness among the five facets of posttraumatic growth may be obscured by the common practice of aggregating the subscale scores to focus on a single index of posttraumatic growth. Thus, future intervention studies should investigate the differential therapeutic mechanisms for different facets of posttraumatic growth, to enhance intervention effectiveness.

This pilot study has limitations that inform future research. First, the present study is not a randomized controlled trial. The JLA participants and the routine care participants were recruited independently and differed in age, time since diagnosis and educational level. In particular, the relatively large group difference in time since diagnosis may result from the differential inclusion criteria regarding time completing treatment. The JLA participants had shorter time since diagnosis than the routine care participants, suggesting that the two groups may be at different stages of psychological adjustment. In the present study, time since diagnosis was not significantly associated with PTGI total score or any subscale scores, which is consistent with previous studies,¹⁵ and we used appropriate statistical techniques to adjust for group differences in age, time since diagnosis and educational level. However, we cannot rule out the possibility that the two groups may differ in other unmeasured covariates, which may produce confounding effects. Moreover, data of the two groups were not collected at the same time. The beginning of data collection for the two groups was nearly four years apart. As a result, the observed findings may be subject to history bias. Thus, the findings need to be confirmed in future randomized controlled trials.

Second, without a direct assessment of participants’ perceived social support, it remains unknown whether social support acts as a pathway for the potential benefit of the JLA intervention in facilitating posttraumatic growth. Besides, alternative mechanisms other than social support may be plausible. For example, some topics of the educational lectures, such as developing positive perspectives about cancer and building self-value, may facilitate cognitive reappraisal. Cognitive reappraisal of trauma has been identified as a crucial element facilitating posttraumatic growth.^41,42 According to the functional-descriptive model of posttraumatic growth,^22,24 the shock of a breast cancer diagnosis may challenge and shatter a person’s core assumptions about themselves and the world. Reappraising the cancer experience as an opportunity for personal growth may help survivors rebuild their world views, and develop new perspectives to adapt to a new life after cancer.^22,43 Future research to examine the potential intervention mechanisms for JLA is warranted.

Third, posttraumatic growth was evaluated as the only outcome variable for the feasibility of this pilot study. Future research should include more measures of psychological adjustment, such as quality of life and perceived stress, to achieve a better evaluation of the potential benefit of the JLA intervention.

Fourth, although the participants in the routine care group were not exposed to the JLA intervention, we cannot rule out the possibility that the routine care participants may be involved in other cancer support groups or community services during the 8-week study period, which may confound the observed findings.

Finally, participants’ posttraumatic growth was assessed immediately after the completion of the JLA program. Thus, whether JLA may be associated with long-term benefits warrants future research that adds long-term follow-up assessments.

Conclusions

The present study suggests the potential benefit of a culturally sensitive group support intervention in facilitating posttraumatic growth for Chinese American breast cancer survivors. The educational lectures and the peer mentor support may well meet the psychosocial needs of Chinese American breast cancer survivors in adjustment to the disease. The community-based partnership involving researchers, community health workers, and clinical practitioners may increase survivors’ engagement in the intervention program. The program design may be adapted to tailor the needs of other ethnic minority cancer survivors.