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Giving is receiving, and receiving is giving. This is the key finding from interviews conducted with 28 African American women and men with cancer who were active participants in dynamic relationships characterized by both giving and receiving. These participants engaged in reciprocal relationships varying in the number of persons involved, types of resources exchanged, and timing of exchange. Findings suggest the need to reconceptualize social support as caregiving and caregiving as social support. This study also points to the need to redesign intervention studies to be more inclusive of components that allow the elderly in illness-related situations to maintain their status as givers in their social networks.
One important aspect of supportive relationships identified as contributing to health and psychological well-being is inclusion in social networks that are reciprocal (Berkman, 1983; Goodenow, Reisine, & Grady, 1990; House & Kahn, 1985; Sarason, Sarason, & Pierce, 1990). Reciprocal networks involve exchanges between two or more persons in which resources are both given and received (Antonucci & Jackson, 1990; Kahn & Antonucci, 1980). Yet, much of social support research reflects a view of these relationships as static, one-sided exchanges within social networks in which individuals only give or only receive (Ikkink & Tilburg, 1999; Liang, Krause, & Bennett, 2001; Williams, 1995). Even when researchers have examined reciprocal relationships among two or more persons, the use of theoretical frameworks emphasizing reciprocity as comprising equivalent exchanges between specific persons has resulted in an oversimplification of these relationships.
The purpose of this study is to explore the dynamics of supportive relationships from the perspective of older African Americans diagnosed with and treated for cancer. They are an exemplar population for studying reciprocal relationships, the dynamics of which have not been fully captured in the social support literature. African Americans have a history of involvement in mutual aid systems of reciprocity used to respond to a variety of stressful situations (Billingsley, 1992; McAdoo, 1982). Their unique experiences in collectively pooling resources to meet their needs, coupled with the fact that they have the highest overall incidence and mortality rates from cancer of any racial or ethnic group (American Cancer Society, 2002), provide an opportunity to view the complex and dynamic processes involved in social support transactions.
What is generally known about reciprocal relationships has been shaped by equity and social exchange theories. According to equity theory, individuals give in proportion to what they have received (Jasso, 1983; Walster,Walster, & Berscheid, 1978). Social exchange theorists have argued that individuals give resources or help to others with expectations that their behavior will be rewarded (Homans, 1974). Therefore, when help is received, the expectation is that the recipient pays back that favor (Greenberg, 1980). Both social exchange and equity theories have influenced the most prevalent views of reciprocal relationships, according to which (a) resources exchanged occur in dyadic relationships, (b) resources exchanged are similar in kind and amount, and, (c) resources received are paid back within specific time periods (Berkman, 1983; Goodenow et al., 1990; McFarlane, Neale, Norman, Roy, & Streiner, 1981; Thomas, Milburn, Brown, & Gary, 1988).
In the health care literature, researchers have concluded that individuals engage in reciprocal relationships when equal amounts of similar kinds of resources are exchanged among specific network members (Buunk, Doosje, Jans, & Hopstaken, 1993; Goodenow et al., 1990; McFarlane et al., 1981) or when the proportion or number of network members giving and receiving support are equal at any given time (Berkman, 1983; Jung, 1990; Liang et al., 2001). One example of the exchange of an equal amount of similar resources is in a study of women with rheumatoid arthritis. In this study, the investigators concluded that those women who received and gave equal amounts of the support of having someone to confide in and of having someone to assist with decision making were involved in reciprocal relationships (Goodenow et al., 1990). Another example of equivalence in reciprocal relationships comes from a study in which reciprocal relationships among a population of college students and their family and friends were examined (Jung, 1990). In this study, the investigators concluded that participants shared reciprocal relationships if the mean numbers of social network members who were givers of supportive resources equaled the numbers of social network members who were receivers of supportive resources.
Reciprocal relationships have also been examined in caregiving research. According to this research, not all reciprocal exchanges are paid back with the same amounts of in-kind resources or even paid back within specific time periods. Studying elder populations, researchers have illustrated variations in reciprocal relationships where the resources exchanged were quite different (Groger, 1992; Ikels, 1988; Ikkink & Tilburg, 1999). In one study, elders shared their homes with others in exchange for money or other services that allowed them to maintain their independence (Danigelis & Fengler, 1990). In another study, elders gave use of their land to their children in exchange for caregiving services and other kinds of support (Groger, 1992). The findings from these caregiving studies clearly suggest the need to consider the different kinds of resources that are exchanged in reciprocal relationships.
The findings from research with elder populations also show that reciprocal exchanges among social networks are not always immediately forthcoming (Antonucci, Fuhrer, & Jackson, 1990; Groger, 1992; Neufeld & Harrison, 1995; Nkongho & Archbold, 1995). In fact, investigators have found that it is possible for reciprocal exchanges to occur after several years have passed. For example, adult children provided gifts to their elderly parents as repayment for previous years of sacrifice in sending them to college (Groger, 1992), whereas other adult children provided for their elderly parents’ caregiving needs as repayment for previous years of assistance and service (Neufeld & Harrison, 1995; Nkongho & Archbold, 1995). These studies are important in that they capture a pattern of repaying support with a resource needed at the time but not initially given and the temporal delay that can occur in reciprocal exchanges.
In addition to the variations of types of resources exchanged and temporal delays, researchers have found other variations in reciprocal relationships that social exchange and equity theories do not consider (Antonucci & Jackson, 1990; Liang et al., 2001; Uehara, 1995; Wentowski, 1981; Williams, 1995). Referred to as communal or mutual aid systems, this kind of reciprocal exchange is oriented toward meeting the needs of the group with whom one is affiliated rather than repaying a resource to a specific individual (Buunk et al., 1993; Liang et al., 2001; Williams, 1995). Indeed, anthropologists and sociologists have a long history of studying reciprocal relationships among populations and have found that cultural translations result in different patterns of social exchanges (Groger & Kunkel, 1995; Pryor & Graburn, 1980; Shi, 1993; Stack, 1974; Yuen-Tsang, 1999). For example, when studying exchanges that occurred among Chinese, Eskimo (authors’ term), and African American populations, investigators found a mutual aid system or communal orientation to reciprocity where network members with increased financial resources gave to those network members with fewer financial resources (Pryor & Graburn, 1980; Shi, 1993). Other investigators have found that network members gave of what they had in exchange for the items they needed (Stack, 1974).
In reviewing the literature on reciprocal relationships, Hupcey (1998) also found that existing models of social support interactions as a one-sided static process were limited, and she proposed models of social support interactions that captured the dynamics of reciprocity. One such model proposed that reciprocity occurs between three persons, with one provider giving support to a recipient, who then pays back a different recipient. However, few empirical studies illustrate the specific dynamics or patterns of these three-person exchanges. Moreover, even fewer studies have focused on these variations in populations experiencing an illness situation. In one study, a variation in reciprocity was noted when, for example, parents providing for personal and health care needs of children with cancer also received the support of money, transportation, and assistance with baby-sitting from family members and friends (Williams, 1995). In this study, the exchange of resources flowed from family member to caregiver and from caregiver to patient. Of note in this study was the finding that those caregivers who were not able to repay family members and friends for the support they provided expressed a desire to repay some other third party in the future. This perspective of repaying support to a potential third person was also demonstrated in mothers of premature infants, who, in their caregiving duties, received support from family members that they were not able to repay (Neufeld & Harrison, 1995). A similar exchange of resources among three or more persons was described in a study with family caregivers of seriously mentally ill patients (Horwitz, Reinhard, & Howell-White, 1996). The exchange of support flowed from family members to caregiver, from caregiver to patient, and from patient back to caregiver. Sometimes resources exchanged were similar; at other times, they were distinctly different.
This study with African Americans diagnosed with cancer provided the opportunity to explore the influence of culture on varying patterns of reciprocal relationships. African Americans have a history of extending familial relationships to persons outside the traditional nuclear family and developing reciprocal mutual aid systems, which has enabled them to survive generations of racial oppression and economic hardships (McAdoo, 1992). Extended family relationships are generally referred to as those close familial relationships among people who otherwise would not be included in the traditional nuclear household (Azibo, 1992; Billingsley, 1968/1988; Blassingame, 1979; Chatters, Taylor, & Jayakody, 1994; Dilworth-Anderson, 1992; Powdermaker, 1937/1993; Stack, 1974). Historians, sociologists, and anthropologists have long debated the origin of extended family relationships among African Americans. Some scholars have argued that the system of slavery destroyed any African culture that existed among African Americans; therefore, the development of extended family relationships occurred in response to the devastating economic conditions experienced throughout history. Other scholars have argued that the system of slavery did not destroy African culture; therefore, the origins of extended family relationships seen in African American culture today are mere extensions of kinship systems that existed in West African culture at the time slaves were brought to America (Blassingame, 1979; Gutman, 1974; Herskovits, 1958/1990).
Historians and sociologists who support the thesis that extended family relationships originated in West Africa have argued that extended and nuclear families were a part of West African culture prior to slavery (Billingsley, 1968/1988; Boles, 1984; Roschelle, 1997). When Africans were separated from these kinship systems and sold into slavery, they adapted their family lives to replace what was lost from their culture. Slaves developed a system of adopting people not related to create an extended kinship system that was similar to their family structure in West Africa (Boles, 1984; Roschelle, 1997). During slavery, this extended kinship system consisted of one or more families residing in one household or it extended across households to link persons together into one large family (Boles, 1984).
Regardless of views about their origin, scholars agree that extended families have been important to the survival of African American families for generations. White (1985) and Jones (1995) described the cooperative nature of slave families working together. During slavery, reciprocal mutual aid systems consisted of African American families working cooperatively both in and out of the fields to overcome the stresses and burdens of slavery. They helped each other with work roles, child care, and other domestic activities to provide adequate food and clothing for the family.
This kinship system of helping each other continued to exist after slavery. In the early years of the 20th century, during the Progressive Era, the living conditions and health status of many African Americans were affected by legal separation and enforced segregationist Jim Crow laws, which restricted access to public accommodations, stores, and even to health care (Rouse, 1989). In Southern rural areas, many African Americans supported themselves through work as sharecroppers. In response to labor exploitation, in which African Americans received little or no pay, families and extended kinship clusters usually stayed together as they migrated from plantation to plantation in their attempts to survive (Blassingame, 1979; Jones, 1995). In Northern urban areas, the economic status of African American families was affected when men were chronically unemployed or sporadically employed as skilled and unskilled laborers. In response, many African American women were required to work in low-paying jobs as domestics and seamstresses (Jones, 1995). From historical accounts, no matter where they were located geographically, living conditions were poor for the majority of African American families during the Progressive Era.
The primary function of extended family systems during the Progressive Era was the sharing of material resources, workloads, and child care (Jones, 1995). One example of the collective efforts of African American families to survive economic hardships during this time was when family members left the low-paying working conditions of the Southern cotton fields and migrated to Northern urban areas. Those African Americans who successfully found work sent money home to benefit other family members (Jones, 1995). There are more historical accounts of this mutual aid system functioning to share material resources. Other examples of these collective efforts can be seen in documentation of incidences in which relatives relocated from one geographic location to another when needed to care for sick family members (Jones, 1995).
Another historical event that encouraged a system of mutual aid among extended family systems was the New Deal Era (Du Bois, 1899/1996). During this time, many African Americans continued their migration to the North, where they occupied the lowest paying positions, as they also did in the South (Jones, 1995). The Great Depression was difficult for all races; it was particularly devastating for African Americans. Poverty for African Americans was so severe in some situations that former slaves believed that access to food, clothing, and shelter was better for African Americans during slavery than during years of the Depression (Hurmence, 1990). To add to the effects of having little or no money for physical necessities, there was the ever-present threat of racism and oppression. African American men continued to experience higher rates of underemployment and unemployment, and died at a much earlier age than did their White counterparts (Jones, 1995; Powdermaker, 1937/1993).
African American women, who previously were limited to employment as domestics, had even more limited work opportunities during the Depression (Jones, 1995). When there was a lack of money, the networks of kin and neighbors became very important to the survival of the African American family by providing mutual assistance as members shared or bartered services for food, shelter, and clothing. Examples of mutual assistance provided among neighbors occurred when one neighbor exchanged a cup of sugar for child care and when a group of neighbors took turns sitting with an older sick neighbor. Jones related the story of one family that took their father, who had suffered a stroke, with them when they went to the fields to work and everyone working in the fields took turns tending to his needs. Another example of this mutual aid system among African Americans comes from an anthropological study of low-income African Americans in which extended family members shared what they had in exchange for what was needed (Stack, 1974). In this network, members were expected to provide what was available to those in need, and, because it was a network of mutual aid, no payment was expected for what was given. African Americans were known to share housing, food, and other household supplies when there was little or no money to lend or borrow (Jones, 1995). With the threat of eviction from their homes, many African Americans formed organized groups to boycott landlords to prevent other families from being evicted from their homes when they were unable to pay the rent.
Studies about the presence of mutual aid systems in the context of harsh economic conditions continued well into the 20th century. Although African Americans benefited from the struggles of the Civil Rights Era, exploitative working conditions and inadequate living conditions continued for many. Poverty among African Americans was at an all-time high (Giddings, 1984). Although they made employment gains during the Civil Rights Era, the majority of African American men and women continued to occupy the least desirable positions in the workplace (Jones, 1995). Regardless of occupation, the pay scale for African Americans was significantly lower than for their White counterparts (Giddings, 1984; Jones, 1995).
In response to continued racism and oppression, limited access to quality health care, decreased material resources, and poorer health status than Whites, African Americans have continued their collective actions both formally and informally to provide for themselves. An informal support system of immediate and extended family, friends, and neighbors continues to share material resources and interact to provide information, encouragement, and validation to members when they have personal or health problems.
Advances have been made in the study of reciprocal relationships; we are in the initial stages of exploring variations and ways in which individuals exchange resources within their networks. However, what continues to be missing from both social support and caregiving research are studies that capture the complexity of the dynamic processes involved in individual perspectives of giver and receiver of social support among two or more persons. Social support research has primarily focused on the support/care received; caregiving research has primarily focused on the support/care given. The findings from this study suggest that giving and receiving, and social support and caregiving, are intimately connected.
The findings reported in this article were derived from open-ended and initially minimally structured interviews with 15 African American women with breast cancer and 13 African American men with prostate cancer. The women in this study had an average age of 60 years (range 42–87), with an average of 13 years of education. At the time of the interviews, 11 women were retired or on medical leave; 8 were not married. All but 1 woman had a history of working in service areas as teachers, nurses, or domestic workers. Only 2 of these women lived alone, but this low number can be attributed in part to family members’ moving in with the participants while they recovered from treatment. According to the United States classification of counties and equivalent areas (Census Bureau, 2001), only 2 of these women lived in nonmetropolitan counties.
The 13 African American men had an average age of 67 years old (range 61–79), with an average of 15 years of education. Eleven men were married, and most were well educated; nine men had college degrees, and three of these men had graduate degrees. All but three of the men had retired or were on medical leave. Their working histories were similar to those of the women, with nine men having worked in service roles, primarily as church ministers or teachers. Five of the men lived in nonmetropolitan counties.
We recruited these men and women from a list of individuals who had completed their participation in one of three studies, the aim of which was to test a psychoeducational intervention delivered to persons being treated for cancer.1 We obtained approval for this study from the Institutional Review Board of the School of Nursing at the University of North Carolina at Chapel Hill and obtained informed consent prior to each interview. Each participant received a written and verbal explanation of the study, its potential benefits and risks, the data collection procedures, and a statement guaranteeing anonymity and confidentiality. Pseudonyms are used to refer to participants in the Findings section.
The first author conducted in-depth interviews with each participant. These interviews were aimed at eliciting descriptions of these participants’ experiences with supportive relationships during the diagnosis, treatment, and posttreatment periods of their cancer trajectory. Participants were interviewed once in their homes, and each interview lasted between 45 minutes and 2 hours. Both women and men were interviewed until informational redundancy was achieved in each group (Sandelowski, 1995). The initial interviews were largely unstructured. Each interview started with a general question: “Tell me about your experience with cancer.” Other general questions included “What helped you through that experience?” and “What has been helpful to you since your diagnosis, and why was that important to you?”We designed these questions to promote an open discussion of the participant’s social support and social exchange experiences, and they reflected the interviewer’s prior sensitization to concepts in health-related, anthropological, and historical literature on social support. As the interviews progressed, the questions became more directed as the interviewer pursued analytic lines that had emerged in previous interviews. Throughout the interviews, she used probing questions when needed to encourage participants to talk about events or people important to their social support experiences.
We used grounded theory techniques to analyze the data (Strauss & Corbin, 1998) for the purpose of further developing existing theory (Strauss, 1970), that is, to refine existing conceptualizations of social support and reciprocal exchanges. Because sampling was confined to persons who had participated in the previously described intervention studies, theoretical sampling consisted of sampling events and incidents of giving and receiving contained in the interview data. We compared these events to each other and to existing concepts of social support and exchanges, and men’s and women’s responses to each other. The analytic focus on reciprocity per se came as a result of our having discerned, after analyzing the first few interviews, that incidents of giving and receiving, and, most especially, of giving as receiving and receiving as giving, were thematic in the participants’ depictions of social support. Data were arranged in intra- and cross-case displays to show each participant with every variation of reciprocal exchanges in which they reported having engaged. The outcome of this work is shown in Tables 1 and and22.
As shown in Tables 1 and and2,2, women and men engaged in reciprocal relationships that varied on the following dimensions: (a) number of persons involved (two or three or more), (b) type of resources exchanged (same or different), and, (c) timing of exchange (short term or delayed/pending). Participants reported engaging in at least two kinds of exchanges; one woman described four kinds of exchanges. In contrast to the literature, in which two-person exchanges appear as the most prevalent kind of exchange, the most frequently described reciprocal relationships described in this study were those involving three or more persons. The most prevalent exchanges in these three-party relationships were of the same resources over a short time. The next two most frequently occurring relationships for both women and men were those involving three or more persons exchanging different resources over a short period, and two-person exchanges of the same resources over a short time span. All of these relations involved persons known to each other, who were usually described as family members or close friends. Less frequently occurring exchanges were those involving three or more persons with exchanges of different resources over delayed time periods, two-person relationships in which in-kind and different resources were exchanged over extended time periods, and relations in which the parties were unknown to each other prior to the exchange. Although theoretically possible, among the women, there were no empirical examples of two-person or three-person relations involving the delayed exchanges of in-kind resources. Among the men, there were no empirical examples of two-person short-term exchanges of different resources or three-person delayed exchanges of in-kind resources. This might be a function of our having interviewed these participants only once and thus capturing their views of social support at only one moment in time.
The following sections contain illustrations of these variations in reciprocity and their meaning to the participants. Discussed first are the three-person relationships, which were most prevalent in participants’ descriptions.
Three-person variations of reciprocal exchanges occurred when cancer patients saw themselves as an integral part of an extended family or kinship system. The variations in this section included at least three persons and were grounded in a belief that one should “Do unto others as you would have them do unto you” (Matt. 7:12).
In this example, the cancer patient received support from one network member and repaid a similar type of support to other network members. Mr. Mason, a 63-year-old, married, retired man with 16 years education who was active in his church, offered an example of a three-person in-kind exchange over a short period of time. Mr. Mason described the information he received about prostate cancer from his brother soon after he was diagnosed and how he immediately shared that information with another member of his network, who had also been diagnosed with prostate cancer. As he observed,
He [my brother] had a prostate cancer operation; he’d already had it. I talked with him and so he told me all the negatives about it and of course the positives. So I was pretty informed about what was gonna take place before I had the operation…[My brother] talked to me about how it’s gonna be some anxieties that will affect you, such as wonder how long before it [the cancer] comes back, wonder how would you know that it’s coming back, all these things. He talked to me about those things.
Mr. Mason reciprocated through sharing the information he had learned from his brother with a deacon of his church who also had prostate cancer. When he had recovered from his surgery, he talked to the deacon:
He had prostate cancer following me. I talked with him and encouraged him. And I encouraged him to do it [have the operation] because of the consequences of not having it. And I tried to tell him all that I knew about it and all the other things I learned about it. And I think I encouraged him to go have it.
An infrequent variation of three-person reciprocal exchanges of in-kind resources over a short time period occurred among persons previously unknown to each other. In these relationships, the person with cancer engaged in helping relationships with individuals with whom they had had little or no previous relationship. These persons received help during cancer treatment and then, after treatment, gave help to another person with cancer. The persons involved in these three-person relationships were linked through known network members and were described as friends of friends or as friends of relatives. No efforts were made to maintain the relationship.
An example is Mr. Malcolm, a 68-year-old retired high school teacher who lived alone with his wife. Although he attended church and was a member of a fraternity, he did not like talking about his personal problems with individuals he knew. As a result, when he was diagnosed with prostate cancer, he was unable to talk about his problem with other men in his network who might have had that experience. The person Mr. Malcolm was able to talk to was his wife’s uncle, a physician and survivor of prostate cancer who lived in another state. Once Mr. Malcolm received help from this person in the form of encouragement, advice, and information, the helping relationship ended. Mr. Malcolm talked about the help he received from his wife’s uncle after he had been diagnosed with cancer. As he recalled,
My wife has an uncle in Mississippi, and he had gone through the same thing and he’s a doctor also, and they were telling me, “Don’t worry about it, everything will be okay.” See, because a year before, two years before, he had the operation. And he said, “At first I was a bit skeptical about it, but don’t worry about it, everything’ll will be okay.” And he called and talked to me for a while.
Mr. Malcolm’s wife’s uncle also offered to help him select another physician if one was needed. Mr. Malcolm recalled talking to his wife’s uncle about the selection of his treatment physician in this way:
And he said, well he didn’t know if he [Mr. Malcolm’s physician] was good or bad, but he said, “If your doctor recommended him and he’s supposed to be head of the whole program, chances are he’s a pretty good person to deal with. But if you are not satisfied with that particular one, I will contact the one I had because I know what he done for me.”
Mr. Malcolm not only received support from someone not previously known to him, but when he was able, he repaid a similar form of support to a younger man he had recently met in a support group who was also diagnosed with prostate cancer. He talked of the support he received in that group but also of being able to provide support to someone else in the group. He observed,
Well, just listening to other [men with prostate cancer], what they’d gone through and sharing the different information and saying what, how I cope with this and how I cope with other things, that was kind of…you knew what to expect because they had been there and you can ask them what to do if this, and so they would tell you the type things. And so one [man in the group] was much younger, he called me a couple of times because he had to go through the same type of operation, he was much younger, and he wanted to know what should he do, he was concerned about his girlfriend, because I don’t know if he had a wife. I said man, you know, go and take—your health is first, and so if the girlfriend, you don’t have any girlfriend after, you have your life, you know, one of them type things. So. And I think he lived by himself, and so I said, you need to have someone there when you come in, because that’s when I needed, because I had to have [help] you know, getting into my bed.
This reciprocal exchange also occurred when the cancer patient received support from one network member and repaid another network member. However, in this instance, the resource exchanged was of a different type.
Ms. White was 65 years old and had never married. She was the mother of two adult children, both of whom lived in other states. Although Ms. White was retired, she remained active in her church missionary group and likened her relationships with other church members to one large family unit. In fact, she called the other women in the church her “sisters.” During the time when she was receiving treatment for breast cancer, Ms. White received help and support in the form of prayers, money, visits, flowers, food, and phone calls from her church family and members of her missionary group. A few months later, when Ms. White had recovered and saw herself as a survivor of breast cancer, she talked about her efforts to give back to others. One instance in which she was able to give back occurred as soon as she had recovered from her breast cancer surgery. Ms. White talked about helping another woman in her church family who had health problems by providing her with transportation to a medical facility and supporting her by simply “being there.” Ms. White did not feel obligated to specific church members who helped her while she was being treated for breast cancer, but as soon as the opportunity presented itself, Ms. White was able to pay back the help she had received by helping another woman. Ms. White had this to say about helping another woman in her church family:
We had one lady there, she had a hernia. I guess that’s what it was. And so I went with her to the hospital for her surgery and brought her home. So that’s the way we work in our church. We do unto others as you wish they do unto you.
A variation of reciprocity among three or more persons was delayed exchanges that occurred when help was previously given in one social network but later received in a different network. (This type of exchange has been linked to older persons whose network members change over time because of death [Kahn & Antonucci, 1980].) Of note here is the belief that previous acts of giving will eventually pay off with help provided when there is a need.
Ms. Carson was an 80-year-old woman who lived alone. Her husband and most of her family had died years before. When Ms. Carson moved to the city in which she currently lived, she formed another network of extended family members and friends. Ms. Carson talked of how she was being repaid for her previous acts of giving in this way:
Some of the people I’ve done this for, they weren’t able to do anything for me. And then this, I figure this way, like I did something for you, but somebody else will do something for me. And so that’s the way it’s been happening.
Ms. Carson had helped family members and friends in the past, many of whom had died or no longer lived in the same neighborhood. However, when she was diagnosed with breast cancer, she received help and support from a different network that included a recent neighbor, two sisters-in-law, and a niece.
Mr. West expressed a similar belief of “doing unto others,” of how previous acts of giving are an assurance of receiving help in times of need. Mr. West noted,
And that’s what happens to people, because it happened to my brother. Wonder where all the boys is. But see, when you don’t go see nobody or nothing, what do you expect? In life you got to check on other people and do for others. See, in order to have a friend, you got to be a friend.
Another variation of three-person relationships occurred when the person with cancer received help and believed that a third person would come into the relationship to repay the debt owed. Here, persons did not feel obligated to repay those who had helped them; rather, they believed people who had helped them would be rewarded in the future.
Ms. Brent was diagnosed with Stage 4 breast cancer and became extremely ill when taking chemotherapy treatments. She felt that many people in her family and church, friends, and neighbors had helped her when she had no money to pay anyone and felt they would get something back that was better than money.
The examples presented in this section exemplify a pattern of reciprocal exchanges that occurred between two persons known to each other. In these two-person relationships, there was an expectation that when help and support were needed, individuals would give or share what resources were available. The exchanges described in these relationships were also grounded in a belief that to receive help and support, one must have previously given help and support.
One example of a two-person relationship that occurred over a shorter time period with the exchange of a similar kind of support was between a woman with cancer and her daughter. Ms. Walker talked of how she protected her daughter and of her daughter’s attempts to be protective during her experience with cancer. She recalled,
I don’t let her know when I am not feeling good because I don’t want to worry her. But no, I don’t tell her if I am not feeling well. Even if I feel bad and she calls me, I, you know, am liable to talk to her so she can’t tell I feel bad.
Ms. Walker’s daughter also protected her in this way:
My daughter kept check on me every minute. Don’t want me to do—right now my daughter don’t want me to do nothing. I go to do something, she says, “Mama [don’t do that].” I say, I’m fine. But she still [is protective of me] and I guess that’s just the way she is.
An example of a two-person exchange of the same resource over a delayed time period came from Mr. Brown and his wife. Mr. Brown was a 79-year-old, married man. Although he was retired, he continued to serve as a church minister on a part-time basis. The two-person exchange here occurred between him and his wife. Mr. Brown initially became ill with prostate cancer. He recalled the help he had received from his wife during the time he was ill from cancer treatments in this way:
She takes me in her arms and caress me and tell me she loves me or something like that, she’s gonna make it alright.
Years later, Mr. Brown’s wife became ill and needed open-heart surgery. He talked about having to take care of his wife and how that helped him recover from his illness:
And then on the top of that when my wife got sick, I had got to the place where I was just about give up, but when she had her surgery, I had to get up, whether I had cancer or didn’t have cancer, I had to start the cooking and I had to start taking care of her. And I went and bought me a brand new lawnmower and I started back cutting my grass.
For Mr. Brown, the obligation to reciprocate when his wife became ill served two purposes. He was needed to take care of his wife, and, in helping his wife, he was distracted from his own illness.
A two-person relationship with the exchange of a different resource over a short time occurred between a woman with breast cancer and her dependent grandchildren. Ms. Golden was a 69-year-old retired schoolteacher living with her son and two grandchildren. Her obligation to care for the children started with her daughter’s death several years ago. Ms. Golden talked extensively of her reciprocal relationship with her grandchildren. She provided for their personal care needs, and, in return, they kept her busy and distracted from her health problems. She described the relationship in this way:
I felt like I guess having these children around here I got to do something. I got to live for them, see because their mother is dead. I’ve got them more or less to raise. They took care of me [during her cancer treatments]. They brought me home from the hospital. Anything that I needed, they saw to me getting it. And they waited on me hand and foot. My children helped me by cooking my food, bringing it to me on a tray. Everywhere I wanted to go they handled me with care. And took me in the car. They never let me just sit at home. Although I hurt, they saw to me going [places]. Dressed me. All of this. Saw to me getting, they said, “pretty” and dressed me and carried me on. And I enjoyed it. And see, that was something that I guess helped me to just go on, because they took a lot of interest in me. A lot of it I love to do myself…But what I couldn’t do for myself, they did it for me. And at the time, my granddaughter was in the band and they were always participating in certain things. Which meant I was not going to let her go and I not go see her, because I always have stuck by my children in whatever they did. Because I guess if I hadn’t had those children, it would’ve played on my mind. But having to run behind those children and do things for them, I think that acted for helping me to get through it.
This example is of a two-person exchange with a different resource over a delayed period of time. The person with cancer described repaying a past favor even though he was ill himself with prostate cancer. Mr. Malcolm was a 68-year-old retired schoolteacher who talked about the importance of helping friends who had provided help or support to him in the past. Mr. Malcolm had this to say about repaying a friend who had helped him several years ago:
So when she was having sickness with her father and mother. And I guess she was surprised when her father passed, I drove down to the place—I forget the name of the place but it’s a long ways. I took time out from my work to drive down there to be supportive of the family. And so I guess she was surprised that I showed up. But you know, when you get someone as a friend, you don’t have a lot of friends this day and time. If you have a friend and they been true and good to you, you been trying to be helpful to them in many ways. Because she used to help me with typing and things of that sort. So I thought maybe I should be as helpful when she was going through a time of special needs. So I drove down and tried to give all the support that I could.
Mr. Malcolm had no plans to repay the network member, but as soon as an opportunity presented itself, the previous act of helping was paid back. Mr. Malcolm had received help in the form of advice and information from his coworker. Several years later, Mr. Malcolm showed his appreciation through his presence at her father’s funeral. Although the reciprocal exchange was delayed and different from that initially received, when there was a recognized need, the help previously received was paid back.
In this study, a major factor that might have influenced the findings was that participants were sampled from a preexisting subject list of cancer patients who had completed a psychoeducational intervention study in which the intervention itself might have constituted a kind of social support. A limitation of the study was that participants were interviewed only once, precluding a longitudinal view of the dynamics of unfolding social support exchanges.
However, despite these factors, the findings from this study suggest the need to reconceptualize both the recipients of social support and its relationship to caregiving. These participants were not passive recipients of help but, rather, active parties in complex and dynamic reciprocal relationships characterized by both giving and receiving. Underlying assumptions of existing social support research are that individuals in illness-related situations are not able or expected to repay help received (Gouldner, 1960; Tilden & Weinert, 1987). However, the findings reported here show that persons with cancer participate in a variety of reciprocal relationships throughout their illness trajectory. Their translation of reciprocity as giving back when there was an identified need and available resource allowed these participants to remain integrated in their networks.
The findings reported here are also important to the study of reciprocal exchanges in caregiving relationships. Just as the typical view of individuals in the social support literature is as passive recipients, there is also the view of persons in caregiving literature as only providers of support. A few investigators of caregiving relationships have found that persons giving support to sick family members and friends also receive positive rewards and support from either the care recipient or other network members (Archbold, Stewart, Greenlick, & Harvath, 1990; Horwitz et al., 1996; Wood & Parham, 1990). Caregivers have received praise and other forms of positive feedback on their quality of caregiving (Picot, 1995) and also feelings of esteem, gratitude, admiration, respect, love, and kindness from the care recipient (Carruth, 1996). Other studies show caregivers receiving more tangible forms of support from other members within their social networks (Carruth, 1996; Horwitz et al., 1996; Williams, 1995; Wood & Parham, 1990). Just as recipients of social support are also givers of social support, caregivers are also care receivers. Social support is a form of caregiving, just as caregiving is a form of social support.
This study may also help to clarify an evolving body of literature on variations in reciprocal relationships. Researchers have approached the study of reciprocal relationships as though the kind of exchanges in which individuals participated were characteristic traits: that is, as if individuals have a preference for reciprocal relationships in which they are repaid immediately for favors given, or a preference for reciprocal relationships in which meeting the needs of network members is the goal (Buunk et al., 1993; Jung, 1990; Liang et al., 2001). Yet, the women and men in this study participated in a system of exchanges that included varied reciprocal relations. The system of reciprocity found in the women and men in this study, whereby individuals contributed resources in a network from which they could withdraw resources at a later time, has been described as similar to a support bank (Antonucci & Jackson, 1990) or social fund (Cattell, 2001; Hawe & Shiell, 2000). When individuals are engaged in this type of system of exchanges, they consciously or unconsciously keep mental records of what they have given and received from this bank over the years. Help and support given are seen as deposits in this support bank. When support is received, it is likened to a withdrawal of previously accumulated funds; subsequently, there is no obligation to reciprocate when support is received because one is withdrawing only from previously made deposits.
The system of reciprocal exchanges described here is also like those described in historical, anthropological, and sociological studies of the extended family of African Americans. Extended families are units of individuals that include family members but also friends and neighbors who function as members of one large family (Azibo, 1992; Chatters et al., 1994; McAdoo, 1992). According to the findings of these studies, extended families of African Americans have long functioned collectively to pool their resources (Billingsley, 1968/1988; Jones, 1995; Powdermaker, 1937/1993). The system of reciprocal mutual aid described in this study is a strategy African Americans have used to survive generations of racial oppression and economic hardships. White (1985) and Jones (1995) have traced this mutual aid system back to slave families, where individuals learned to share what resources were available to them to ensure the survival of the group as a whole.
There are several benefits from participation in reciprocal exchanges based on the collective resources of social networks. One benefit is that when there is the perception that receiving support is similar to withdrawing from accumulated resources, any feelings of obligations and associated stress from having to repay any single individual are decreased (Thoits, 1995). This is particularly important for the person in an illness-related situation, who might already be experiencing tremendous stress from a disease. Another benefit is possibly derived from the perception of having available support from the association with a vast network versus a dependency on obtaining resources from one or two close relationships.
The findings about group reciprocity with deposits and withdrawals, likened to a banking system among persons with cancer, also raise the question of whether there are rules and expectations governing these relationships, that is, are there norms for behaviors for persons making deposits or withdrawals from this support bank or social fund? Is it acceptable for individuals to make withdrawals from the bank when they may have made very few, if any, deposits into the bank? There is also the question of whether it is possible to overdraw on funds or even to make inappropriate withdrawals without incurring negative responses by network members.
The findings of this study suggest the complex and dense nature of social networks and how network members function to link persons with shared experiences in supportive relationships. Other researchers have noted the formation of networks based on shared experiences (Pillemer & Suitor, 1996; Williams, 1995). The formation of supportive relationships between individuals with shared experiences might have a dual purpose. First, it provides individuals with the opportunity to repay a form of support previously received. For example, when parents of children with cancer received support, they expressed a desire to help other parents in the future (Williams, 1995). Second, these relationships allow individuals to obtain support from persons who, they believe, will better understand their experiences (Pillemer & Suitor, 1996). This study also shows how networks can function to bring together persons with shared experiences. These linkages allow the person with cancer in the treatment phase of the cancer trajectory to develop reciprocal relationships with persons with cancer in the posttreatment phase of the cancer trajectory.
The findings reported here also have implications for the design of measures and intervention studies. Whereas social support instruments primarily assess the support perceived to be available from their social networks, this study shows the need to focus on measures that capture the support individuals give as well as receive. Few measures are designed to assess the reciprocity that exists between individuals and their networks; equity in one-time exchanges between specific individuals has been a primary focus of these measures. Based on this research, a measure of reciprocity would capture the perception that individuals have been able to contribute to a support bank and the perception that resources are available for withdrawal from a support bank. Refined measures for determining reciprocity in relationships should have a longitudinal focus and be designed to capture the varying time periods over which reciprocity occurs.
Finally, this study points to the need to redesign intervention studies to be more inclusive of components that facilitate persons in illness-related situations to maintain their ability to contribute resources to their social networks. Social support and psychosocial intervention studies have typically focused on supplementing or replenishing forms of support that are lacking or not available (DeJoseph, Norbeck, Smith, & Miller, 1996; Fisher, 1997). However, intervening to find meaningful ways to give back and not just receive has been identified as an important part of healthy aging (Bryant, Corbett, & Kutner, 2001) and possibly other phases of life. As such, intervening to assist individuals in illness situations to continue to give back or resume those roles as soon as possible should be a necessary component of psychosocial intervention studies. The inclusion of these kinds of strategies in intervention research is likely to further enhance the self-esteem and psychological wellbeing of individuals in illness-related situations.
This study was supported by (a) a Minority Supplement for Graduate Research Assistant Training to “Managing Uncertainty in Cancer Studies: Self-Help in Breast Cancer,” National Cancer Institute, National Institutes of Health, R01 CA 57764, 1995–1997, Merle Mishel, Ph.D., R.N., F.A.A.N., Principal Investigator; (b) the University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center Research Award in Cancer Prevention & Control and Cancer Epidemiology, 1998– 1999, Jill B. Hamilton, Principal Investigator; (c) the University of North Carolina at Chapel Hill, School of Nursing Institutional Predoctoral Fellowship, National Institute of Nursing Research, National Institutes of Health, T32 NR01 7091, 1997–1999; and (d) a Minority Supplement for Graduate Research Assistant Training to “Managing Uncertainty in Older Breast Cancer Survivors,” National Cancer Institute, National Institutes of Health, R01 CA 78955, 1999–2000, Merle Mishel, Ph.D., R.N., F.A.A.N., Principal Investigator. The authors thank Merle Mishel and Carrie Braden for facilitating access to the participants in their studies; and Barbara Stewart, Lillian Nail, Virginia Tilden, and Gerontology Seminar participants at OHSU for their review of earlier drafts of this article.
1Participants for this study were recruited from three federally funded studies, including “Managing Uncertainty: Self-Help in Breast Cancer Study,” National Cancer Institute, National Institutes of Health, 1R01CA57764-01A2, 1993–1996, and “Managing Uncertainty in Stage B Prostate Cancer,” National Institute of Nursing Research, National Institutes of Health, 1R01NR003782-01, 1993–1997, Merle Mishel, Ph.D., R.N., F.A.A.N., Principal Investigator; and “Promoting Self-Help—Underserved Women With Breast Cancer,” National Cancer Institute, National Institutes of Health, 1R01CA064706-01, 1994–1998, Carrie Braden, Ph.D., R.N., F.A.A.N., Principal Investigator.
Jill B. Hamilton, postdoctoral fellow at Oregon Health & Science University’s School of Nursing, Portland.
Margarete Sandelowski, Cary C. Boshamer Professor of nursing at the University of North Carolina at Chapel Hill.