Emerging Adults’ Peer Acceptance of Those Who Appear to be Undergoing Chemotherapy

Abstract

Physical appearance has been shown to be heavily influential in the overall peer acceptance of an individual. Yet, the role of a changing physical appearance due to an illness (e.g., cancer) and its impact on peer acceptance has garnered little focus. This study considered how appearing as if undergoing treatment for cancer impacted peer acceptance in emerging adults. Using photo vignettes, a sample of 182 emerging adults (79 percent female; 21 percent male) evaluated four types of hypothetical emerging adult peers. Results showed that the healthy models had significantly different peer acceptance scores compared with the chemotherapy models. A positive association between microsystem exposure to cancer and peer acceptance ratings was also found. Clinical applications to foster more microsystem influences, such as social support groups on university campuses, and future directions, such as the use of video vignettes, are provided.

Keywords

physical appearance peer acceptance chronic illness emerging adults cancer

Emerging adulthood is a distinct developmental period in industrialized nations that begins around the age of 18 and ends around 25 (Arnett 2002, 2015a, 2015b; Montgomery 2005) and is characterized by five distinguishing features, including the age of identity exploration and age of instability. During this time, emerging adults have an extended period to explore their identity because of an earlier onset of puberty as compared with previous generations (Arnett 2002) and the delay of taking on traditional adult responsibilities (e.g., marriage and work; Copen et al. 2012). With this exploration comes various choices to make regarding life (e.g., college, career, living arrangements) that create instability (Arnett 2002, 2015a). Despite the lack of stability across school and living situations, peers become one of the constant, direct influences in the lives of emerging adults (Arnett 2002; Pascarella and Terenzini 1991) compared with the influence of parents in the preceding years. In the context of peers and relationships, emerging adults are learning more about themselves and what they desire in another person for the future, compared with adolescents who are more concerned about the here and now (Arnett 2015a). Therefore, it is imperative to examine aspects of peer relationships within emerging adulthood.

A diagnosis with a chronic illness like cancer can intensify the lack of stability emerging adults feel, especially when coupled with changes in physical appearance brought on by the chronic illness. Despite knowing that physical appearance influences peer acceptance among children (e.g., Iobst et al. 2009) and adolescents (e.g., Kingery, Erdley, and Marshall 2011), little is known how, or if, it influences peer acceptance among emerging adults. Peers could be an important source of support for emerging adults with cancer, and knowing how peers may be influenced by physical changes caused by cancer is necessary. Thus, this study relied on a vignette technique that assessed emerging adults’ peer acceptance of four hypothetical peers, two of whom appeared to be undergoing chemotherapy.

Theoretical Framework

Bronfenbrenner’s ecological theory can help provide a basis for understanding the importance peers play to an individual as well as how a cancer diagnosis may impact that individual. Ecological theory attempts to explain the different influences on development, including environmental contexts and time (Bronfenbrenner 1979). The environmental contexts are conceptualized as four nested subsystems: microsystem (the immediate environments), mesosystem (interactions between microsystems), exosystem (indirectly influences a microsystem), and macrosystem (characteristics of the culture; Bronfenbrenner 1994), which are constantly being influenced by one another (Bronfenbrenner 1979) and the changes or lack thereof over time (Bronfenbrenner 1994). For the purpose of this study, peers are situated as part of the microsystem and cancer as a nonnormative change over time.

A microsystem system is an immediate environment experienced by the individual (Bronfenbrenner 1994). Examples of microsystem settings are work, home, daycare, and school, including the individuals belonging to those settings, such as peers. Researchers readily agree that peers are influential in the development of an individual. Peer relationships provide individuals with help, models for self-referencing, sources of approval (Klima and Repetti 2008), and a way to learn about their self (Engle, McElwain, and Lasky 2011). Studies have shown that individuals who have been rejected by their peers are at risk for negative externalizing and internalizing behaviors. Although much research has been produced emphasizing the influence of peers, little research has focused on the influence of peers on emerging adults. Although an emerging adults’ years are marked by the instability of their lifestyle (Arnett 2002), peers become more of a direct influence during this time period compared with parents (Arnett 2002; Pascarella and Terenzini 1991), suggesting a shift in the influences from microsystem. Despite this shift, research is lacking in the specifics of peers in emerging adulthood. This study aims to add to this research by studying peer acceptance in a sample of emerging adults.

Bronfenbrenner defined time, or the chronosystem, as the changes or lack of change of the person and their environment at any given time (Bronfenbrenner 1994). These changes, also called life transitions, can be separated into normative (e.g., starting college at 18) and nonnormative events (e.g., a cancer diagnosis; Bronfenbrenner 1986). The nesting structure of the of the environmental contexts means that any life transitions experienced in the chronosystem will affect the individual’s four other subsystems. For example, a child who is diagnosed with cancer (a nonnormative event within the chronosystem) is introduced to a new culture (“hospital culture”; Gillmor 2001; change in the macrosystem). Furthermore, the child’s parents may have to take time off of work that may cause a strain at work (influence on the exosystem), and the added strain from the diagnosis and work may cause the parents to fight more (impact on the mesosystem). Finally, the child may not be able to spend as much or any time with his or her peers because of being in the hospital (change in the child’s microsystem). Therefore, a nonnormative event within the chronosystem, such as cancer, can have an impact in the peer relationships of the individual.

Physical Appearance And Peer Acceptance

The physical attractiveness of peers has been found to be the strongest correlate in peer acceptance, over and above sociability and athletic ability (Vannatta et al. 2009; Zakin 1983). More recently, Lansu and Cillessen (2012) found physical attractiveness as a common characteristic among accepted and popular peers. The connection between physical attractiveness and peer acceptance begins in early childhood. For example, children as young as three assigned fewer positive words to an overweight model, especially if they blamed the model for being overweight (Iobst et al. 2009). Both males and females have less anxiety about others’ perceptions of their own bodies if they have positive perceptions of their own bodies (Davison and McCabe 2006), this may be particularly strong with females (Seidah and Bouffard 2007). Seidah and Bouffard (2007) note, however, that when males base their self-esteem on their physical appearance, then their relationship between self-perceptions of physical appearance and anxiety regarding others’ perceptions becomes more similar to females. Furthermore, college students similarly perceived that media sends messages that men should be lean and muscular and women, thin (Gillen and Lefkowitz 2009). Women, however, were more likely than men to internalize the message that meeting the ideal physical attractiveness would lead to success. Thus, physical appearance plays an important role in how individuals perceive themselves and others, but the role of physical changes brought about by chronic illness like cancer among emerging adults remains unclear.

Cancer in Emerging Adulthood

According to the World Health Organization (2018), chronic illnesses last for an extended period of time and progress slowly, which classifies cancer as such an illness. There are a variety of ways to treat cancer, each carry the possibility of physical side effects. Radiation is the use of high doses of radiation beams aimed directly at the cancer cells (American Cancer Society [ACS] 2018; National Cancer Institute 2018). Side effects of radiation include, but are not limited to, skin irritation/damage, hair loss, nausea, fatigue, bleeding, and fibrosis. The presence and severity of these side effects depends on length of the treatment, location of the radiation, and dosage (National Cancer Institute 2018). Surgery can also be used to diagnose and/or treat cancer (ACS 2018). Depending on the type of cancer and the reason for surgery, possible side effects and/or permanent changes are visible medical apparatuses, bleeding at the site of the incision, loss of limb, shaved body areas, and bruising. Finally, chemotherapy (or chemo) is the use of medications that travel throughout the entire body with the intent of attacking cancer cells (ACS 2018). Common characteristics for individuals taking chemo include hair loss, bleeding, nausea, skin and nail changes, bruising, weight gain, and mouth, gum, and throat problems (ACS 2018; National Cancer Institute 2018). Thus, individuals with cancer may experience changes in their physical appearance during and after their treatments, which could impact peer relationships.

Research has shown that upon the diagnosis of a chronic illness (e.g., cancer, cystic fibrosis), individuals are more likely to report changes in their social lives than their healthy counterparts. For example, children and adolescents diagnosed with cancer are more likely to display signs of social withdrawal (Benner and Marlow 1991; Glasson 1995; Mattsson et al. 2007; Meltzer and Rourke 2005; Pini, Hugh-Jones, and Gardner 2012; Roberts, Turney, and Knowles 1998; Schultz et al. 2007) and have less exposure to peers, which reduces their opportunity for peer acceptance (Mattsson et al. 2007; Noll et al. 1991). They also have reported feeling behind emotionally, physically, and socially (Glasson 1995) because of interruptions in their interactions with old friends and peers (Chekryn, Deegan, and Reid 1986; Pini et al. 2012) and an altered physical appearance (Bellizzi et al. 2012; Pini et al. 2012). A systematic review of adolescents and young adults with cancer revealed that these individuals experience stigma due to their changed physical appearance (e.g., hair loss; Warner et al. 2016), suggesting that the combination of chronic illnesses and physical appearance combine to impact peer acceptance. Less is known about how peer relationships in emerging adults are affected by cancer.

Researchers readily agree that peers are influential in the development of an individual. Peer relationships provide individuals with help, models for self-referencing, sources of approval (Klima and Repetti 2008), and a way to learn about their self (Engle et al. 2011). Numerous studies have shown that relationships with one’s peers have an impact on social development. The role of peers is less clear among emerging adults. According to Arnett (2015b), emerging adults become less reliant on their peers due to the transition to college with the resulting decrease in number of friendships, likely interaction with a romantic partner, and more time spent alone. Researchers, however, have found that young adults with cancer often report challenges among their peers because of treatment and that these disruptions in their social networks can continue through two years after the diagnosis (Husson et al. 2017). Others have found that poor social functioning among emerging adults with cancer can lead to physical and mental health disturbances (Cacioppo and Hawkley 2003). Thus, understanding how peers perceive peer relationships with those who have cancer would be important to learn which emerging adults may be at risk for poor peer relational outcomes and to better understand what services may be necessary.

Justification For the Study

Physical appearance is a significant determining factor of peer acceptance, and physically attractive individuals tend to have higher peer acceptance rates than those not perceived as physically attractive (Iobst et al. 2009; Lansu and N Cillessen 2012; Vannatta et al. 2009; Zakin 1983). Individuals who have cancer often experience extreme physical changes, including hair loss, sunken eyes, weight loss, pallor, and fatigue related to chemotherapy treatments. Because peer acceptance has been found to be an important influence on the individual, understanding how emerging adults think about hypothetical peers who appear to be undergoing chemotherapy is an important first step in learning how emerging adults with cancer may be perceived by their peers. Furthermore, the information learned in this study may be of use to practitioners and hospital staff who work with emerging adults with cancer as they become healthier and re-enter their social worlds.

Emerging adulthood has been shown to be a distinct period from adolescence and young adulthood (e.g., Arnett 2002), but few studies have specifically examined this age group. Even fewer studies have assessed peer relationships of emerging adults despite finding that peers become more of an intentional influence than in adolescence (Arnett 2002; Pascarella & Terenzini 1991). Previous research on peer relationships suggests that individuals who are accepted by their peers have a lower likelihood of dropping out of school (Parker and Asher 1987) and better later social adjustment (Bagwell, Newcomb, and Bukowski 1998; Kingery et al. 2011). Emerging adulthood is characterized by instability, and it is likely that a cancer diagnosis would only accentuate this because of the nonnormative transition. In addition to changing living situations, schools, and jobs—typical changes for emerging adults—cancer diagnoses could involve frequent doctors’ visits, hospital stays, interactions with new groups of individuals (e.g., doctors, nurses, therapists), and altering daily schedules for the benefit of their health, which in turn impacts their available time to interact with their peers.

Arnett (2015a) also proposed that emerging adults are attempting to define their identity by exploring possibilities by asking, “Who am I?” They can begin to answer this question by exploring new ways to live and new people to get to know, such as expanding current peer relationships or creating new ones. A cancer diagnosis may limit potential possibilities for emerging adults to explore who they are and what they enjoy, which may in turn alter their identity development. Considering that their identity development can be influenced by their experiences with their chosen peers (Arnett 2015b), it is imperative to explore how peer acceptance impacts those with a chronic illness, such as cancer.

Research on how medical conditions influence peer acceptance among children and adolescents has been mixed. For example, some have found that children view peers who visibly have a medical condition as not as well-liked as those without a medical condition (King, MacDonald, and Chambers 2010). Gray and Rodrigue (2001), however, found that ratings of hypothetical students with and without cancer did not differ, and, in fact, participants had more positive behavioral intentions toward the hypothetical students with cancer. In addition, regardless of the model’s healthy status, hypothetical female students were seen more positively than the hypothetical male students. Finally, Pendley, Dahlquist, and Dreyer (1997) reported no differences in the physical attractiveness ratings between adolescent cancer survivors and their healthy counterparts. These results suggest that the knowledge of a person having cancer is not the sole determent for peer acceptance, but it remains unclear how a cancer diagnosis impacts peer relationships among emerging adults as opposed to adolescents.

The Current Study

Emerging adults are more likely to develop relationships with a variety of people to gain a better understanding of who they are as a person and what they want in the future (Arnett 2015a). This suggests that, compared with younger individuals, emerging adults may be more willing to form relationships with peers who have cancer, but there is no existing research to confirm this supposition. Thus, the results of this study could be used by health professionals to better address how a diagnosis of cancer may influence emerging adults and their peer relationships. Helping support the peer acceptance of emerging adults with cancer could lead to diminished psychological distress, loneliness, and college drop-out rates, all of which could have long-term effects on the life course of an emerging adult. Two hypotheses were tested as well as a research question were explored:

Hypothesis 1: There would be differences in the peer acceptance rates of the chemotherapy vignettes and the health vignettes.

Hypothesis 2: The female model who appeared to be undergoing chemotherapy would have different peer acceptance ratings compared with the male model who appeared to be undergoing chemotherapy.

Research Question: What is the relationship between the number of people participants know who have had cancer and participant ratings of peer acceptance?

Method

Participants

This exploratory design used a convenience sample of 182 participants from a mid-Atlantic state university recruited through the university’s electronic messaging system. Participant selection was guided by the following criteria: (1) They must be between the ages of 18 and 26 years (Arnett, 2002, 2015a, 2015b; Montgomery 2005); (2) The participants must be unmarried; (3) The participants must not have children. Few participants did not qualify for the study (n = 17), all of whom were outside of the age range. The mean student age was 20.85 years (SD = 1.89; range = 18–26), with majority of the sample female (79 percent) and Caucasian (87 percent). Few of the participants had a chronic illness (11 percent). When specifically asked about cancer and their ecological exposure, two participants had cancer, 56 had an immediate family member with cancer, 109 had an extended family member who had/has cancer, 80 had a friend with cancer, 79 knew an acquaintance with cancer and 13 indicated never knowing anyone with cancer.

Procedure

After reading the letter of consent, participants were directed to a series of questions to determine eligibility (between the ages of 18 and 26, unmarried, no children). Participants who did not meet the criteria were told that they did not meet the criteria for the study, were thanked, and then automatically exited out the survey. Next, each participant was randomly given one of four photo vignettes with an accompanying written description of the vignette provided. Participants were fairly evenly distributed across all four vignettes (n = 47 healthy female; n = 43 healthy male; n = 44 chemotherapy female; n = 48 chemotherapy male). Following the vignette, participants were given the Peer Acceptance Measure and a brief demographic questionnaire.

Vignettes

Four picture vignettes (visibly health male/female, male/female who appear to be undergoing chemotherapy; see Figures 1–4) with an accompanying written description were developed based on previous research. In alignment with Gray and Rodrigue (2001) and King et al. (2010), the vignettes reflected both male and female genders and were of a similar age as the participants. To ensure the pictures used for the vignettes were age appropriate, an undergraduate class was given a photo of the male model and asked, “How old (in years) do you think this person is?” The same was done for the female model. The mean reported ages for the male and female models were 19.22 (SD = 1.42) and 19.96 (SD = 1.30), respectively.

Figure 1.

Photo vignettes.

The vignettes who appeared to be undergoing chemotherapy (i.e., the chemotherapy vignettes) was created by applying make-up to the same models for the healthy male/female vignettes to make them appear paler and more tired for the photos, and the digitally removing their hair to appear bald, which are common symptoms of undergoing chemotherapy (e.g., pale skin; ACS 2018). To check for health assumptions for chemotherapy vignettes, a second undergraduate class was asked, “What do you assume about these persons’ health?” Over 60 percent responded with “cancer,” indicating that the chemotherapy vignettes were representative of a person undergoing chemotherapy. Figure 1 includes pictures of each vignette.

Accompanying each picture was a small paragraph explaining how the participant knows the hypothetical student. Two separate written vignettes were used: one for the healthy models and one for the models who look as if they are suffering the effects of chemotherapy.

Healthy Model Written Vignette

This is a college student at a university similar to yours. S/he attended college after s/he graduated high school when s/he was 18. S/he wasn’t sure what to major in when s/he began college, but has recently decided on what s/he thinks s/he wants to do after graduation. Even though s/he graduated from high school not that long ago, s/he feels older and different than most adolescents still in high school. Further, even though a lot of people call him/her an adult, s/he doesn’t quite feel like an adult. S/he has some anxiety about what s/he’ll do after graduation, but also is excited for what may happen after college. Outside of typical sicknesses (e.g., colds, flus), s/he has been healthy for most of his/her life. Rarely has s/he missed school because of sickness, and s/he seldom has missed college classes because of illness.

Chemotherapy Model Written Vignette

This is a college student at a university similar to yours. S/he attended college after s/he graduated high school when s/he was 18. S/he wasn’t sure what to major in when s/he began college, but has recently decided on what s/he thinks s/he wants to do after graduation. Even though s/he graduated from high school not that long ago, s/he feels older and different than most adolescents still in high school. Further, even though a lot of people call him/her an adult, s/he doesn’t quite feel like an adult. S/he has some anxiety about what s/he’ll do after graduation, but also is excited for what may happen after college. S/he has been diagnosed with cancer and is currently undergoing treatments, which have caused him/her to lose his/her hair. S/he often feels sick and/or tired, but wants to attend class as often as s/he can. Unfortunately, because of his/her treatments and how s/he feels afterwards, s/he has missed school often because of sickness.

Students were asked to look at the picture, read the accompanying description, and answer the Peer Acceptance Measure and then the demographics.

Measures

Peer acceptance

Fifteen questions on a 5-point Likert scale were developed specifically for this study to assess peer acceptance of the vignettes. The items asked the likeliness of the model’s hypothetical peers’ (i.e., the participants’) willingness to engage in a number of activities with the model as well as items measuring the extent to which participants believe that the model’s physical appearance influences peer acceptance, and participants responded on a 5-point scale from 1 (none) to 5 (all). Participants were asked to respond from the model’s hypothetical peers’ points of view because previous research has indicated that personally held and cultural stereotypes have been found to highly correlate (Gordijn, Koomen, and Stapel 2001). A sample of 37 undergraduates were asked to read each item and determine if it was an acceptable measure of peer acceptance. If not, they were asked to provide an explanation. In addition, it was requested that each student make suggestions of other ways peer acceptance could be measured. Two items from the original peer acceptance measure were removed after the focus group was conducted. The peer acceptance items “____ of this person’s classmates would want to work out together outside of class” and “____ of this person’s classmates would want to grab dinner and/or drinks outside of class” were removed based on a 66 and 50 percent rejection, respectively. The items were replaced with “____ of this person’s classmates want to sit near them in class” and “____ of this person’s classmates want to pick this person as a partner in class.” The resulting peer acceptance measure was reliable (α = .86).

Results

All statistical analyses were done in SPSS 28.0 (Statistical Package for Social Sciences). Given that the data did not fit requirements for a one-way analysis of variance (ANOVA) (i.e., the data were not normally distributed), the Kruskal–Wallis test was conducted to determine if the groups median values of their peer acceptance rates differed across the four photo vignettes: healthy female (HF), healthy male (HM), female who appears to be undergoing chemotherapy (CF), and male who appears to be undergoing chemotherapy (CM). Results showed the groups differed significantly on the median values of their peer acceptance rates (H = 33.67, p < 0.001). Post hoc analyses using the Dunn test revealed support for the first hypothesis. The median values of the peer acceptance rates for the chemotherapy female vignette were different from both the healthy male (p = .003) and female (p < .001) vignettes. The median values of the peer acceptance rates for the chemotherapy male vignette were different from both the healthy male (p = .01) and female (p < .001) vignettes.

A second, and related, hypothesis was that the female model who appeared to be undergoing chemotherapy would have different peer acceptance ratings compared with the male model who appeared to be undergoing chemotherapy, which was not supported.

The purpose of the research question was to examine whether there was a relationship between the number of people participants knew who had cancer and participant ratings of peer acceptance. This question was tested by running a bivariate correlation with these two continuous variables. The analysis indicated that there was a significant positive association, meaning that as the number of people individuals participants knew with cancer increased, so did their peer acceptance scores (r = .20, p = .01).

Discussion

The intent of this study was to study how physical appearance influences perceived peer acceptance of healthy individuals and individuals who appeared to be undergoing chemotherapy, using picture vignettes and a survey. The two hypotheses and research question of this study are explained and interpreted further.

Hypothesis 1

The healthy vignettes had significantly different median values of their peer acceptance scores than the chemotherapy vignettes. These results suggest an important difference in the peer acceptance of individuals who appear healthy versus those who do not. These results could have important ramifications for emerging adults who are diagnosed with cancer, as they may believe they will become social outcasts. Previous studies have indicated that a perception of strong social support is related to positive psychological outcomes for cancer patients (e.g., Costa-Requena, Arnal, and Gil 2015). At the outset of a cancer diagnosis, a college student might already perceive their social support as lacking, which in turn could negatively impact their health. We also must consider the expectations an emerging adult holds regarding a college experience. Emerging adulthood, a normative event within the chronosystem of Bronfenbrenner’s theory, comes with a certain set of expectations: more independence from parents, increased interactions with peers, and increased opportunities for self-exploration (Arnett 2015a). Receiving a cancer diagnosis, a nonnormative event of the chronosystem, however, might lead to emerging adults questioning previously held expectations about that phase of development (e.g., Will I be able to or feel like hanging out with friends? Will I have time or be able to go to classes?). To proactively combat these assumptions, awareness programs could be created on university campuses to help support emerging adults with cancer. In addition, health professionals (e.g., nurses, therapists) could facilitate small groups for these emerging adults to encourage peer social support with new aspects of their microsystems.

Hypothesis 2

It was hypothesized that the male and female model who appeared to be undergoing chemotherapy would have different median values of their peer acceptance, which was not supported. This is in contrast to other research, which has provided support for the assertion that females are perceived differently than males (Gray and Rodrigue 2001). As our demographic data showed, majority of our sample knew of someone within their microsystem that had cancer and, therefore, our sample could have more understanding as to the impact cancer has on someone (e.g., tiredness, inability to go out due to a compromised immune system), regardless of their gender.

Research Question

Given that the chronosystem impacts the four other systems and that a person’s microsystem has the ability to elicit and sustain development (Bronfenbrenner 1994), we sought to examine the relationship between the number of people the participants knew who had cancer and their peer acceptance ratings. Results revealed that there was a positive correlation between the number of people the participants knew who had cancer and peer acceptance ratings, meaning that the more people that the participant knew who had cancer the higher the peer acceptance scores. This result is not surprising given that a cancer diagnosis is an example of a nonnormative event within the chronosystem, which can change the microsystem characteristics. In this study, only 13 participants had a microsystem not influenced by cancer and the remaining 169 had a microsystem that was influenced by cancer in some way. This suggests that as cancer increasingly impacts individuals’ microsystems, they become more sensitive to people undergoing chemotherapy. Therefore, emerging adults with low exposure to cancer in their microsystems could be encouraged to volunteer at local hospitals in order increase their understandings of and sensitivity to individuals undergoing chemotherapy.

Limitations and Future Research

This study adds to the existing literature on the impact of physical appearance on peer relationships by examining physical appearance in the context of a chronic illness with emerging adults. However, continued research in this area is needed to distinguish the multiple influences that an altered physical appearance from a chronic illness has on peer relationships. For example, chronic illnesses that impact physical appearance (e.g., cancer) may lead to different influences on the perceptions of peer acceptance than chronic illnesses that do not impact physical appearance (e.g., celiac disease). In other words, chronically ill individuals who have had their physical appearance altered by their illness may be more accepting of peers who are physically different as compared chronically ill individuals who have had no impact to their physical appearance. Furthermore, it could be that the severity of the variety of chronic illnesses would differently impact individuals’ ratings of peer acceptance because of the likely integration with a new chronosystem (e.g., hospital culture; Gillmor 2001). Future work could be done to better understand how experience with an event mitigates perceptions held of that event.

It is unclear if individuals with a chronic illness may be more or less accepting of others with an illness; our sample consisted of few students who had a chronic illness (11 percent). Therefore, we suggest that future studies should consider testing the moderation of a chronic illness diagnosis on peer acceptance of those who appear sick. It could be that individuals who have a chronic illness might be more sympathetic to the plight of another person with an illness, and therefore may be more accepting.

Future research should also consider utilizing qualitative methods in addition to quantitative methods. For example, participants’ ratings may reflect complex reasoning that are not able to be identified in a quantitative measure. For example, a participant may have rated the ability of the hypothetical model who appears to be undergoing chemotherapy as low, but came to that decision out of the expectation that the hypothetical model may not feel well enough to spend time with peers outside of class. Qualitative data would provide the opportunity for the emerging adults without cancer to explain their reasoning for indicating specific levels of peer acceptance.

Finally, the intent of the study was to explore peer acceptance of emerging adults based on physical appearance, but this work takes the first step to exploring this topic through a variety of lenses. For example, Goffman’s theory of dramaturgy and gender theory could provide a foundation to further explore the gender differences in peer acceptance of those with a chronic illness. Previous work (Lansu and N Cillessen 2012; Vannatta et al. 2009; Zakin 1983) indicates that females have higher peer acceptance ratings based on their physical appearance than males, but it is unclear if this would hold true if the different physical appearance were caused by an external influence (e.g., cancer).

Conclusion

A person’s physical appearance has been found to be a strong influence in peer acceptance (Lansu and Cillessen 2012; Vannatta et al. 2009; Zakin 1983). Despite the stable influence of peers during this developmental period (Arnett 2002; Pascarella & Terenzini 1991), there remains a gap in knowledge in the peer relationships of emerging adults. This study added to that literature by finding that physical appearance could have an impact on the peer acceptance of emerging adults. With the normative and nonnormative events of the chronosystem occurring throughout each person’s life span, changes occur which include physical changes of the individual. By studying the impact of physical appearance on peer acceptance, professionals could better equipment school curriculum, other professionals, and parents to handle this influence. In addition, a positive relationship exists between the microsystem exposure to cancer and peer acceptance ratings. It is important that physical appearance is examined in the context of a chronic illness due to the large number of people affected (six in 10 adults; Centers for Disease Control and Prevention 2021) and the affect it has on their ecological systems. Future research should continue pursue how physical appearance in the context of a chronic illness influences peer acceptance.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Megan Mikesell

Author Biographies

Megan Mikesell, MA, is a doctoral candidate at West Virginia University in the Interdisciplinary Education program. Her research focuses on people’s attitudes toward chronic illnesses and how they impact interpersonal relationships.

Jessica Troilo, PhD, is an associate professor at West Virginia University. She teaches, conducts research on perceptions of fathers, divorce, and families, and is associate dean for academic affairs.

References

American Cancer Society. 2018. “Chemotherapy Side Effects.” Retrieved May 3, 2018. (https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/chemotherapy/chemotherapy-side-effects.html/)

Arnett

Jeffrey J.

2002. “Emerging Adulthood: A Theory of Development from the Late Teens Through the Twenties.” American Psychologist 55:469–80.

Arnett

Jeffrey J.

2015a. Emerging Adulthood: The Winding Road from the Late Teens through the Twenties. New York: Oxford University Press.

Arnett

Jeffrey J.

2015b. “Socialization in Emerging Adulthood: From the Family to the Wider World, from Socialization to Self-Socialization.” Pp. 208–31 in.” Handbook of Socialization: Theory and Research, edited by by J. E. Grusec, and P. D. Hastings. New York: The Guilford Press.

Bagwell

Catherine L.

Newcomb

Andrew F.

Bukowski

William M.

1998. “Preadolescent Friendship and Peer Rejection as Predictors of Adult Adjustment.” Child Development 69(1):140–53.

Bellizzi

Keith M.

Smith

Ashley

Schmidt

Steven

Keegan

Theresa H. M.

Zebrack

Brad

Lynch

Charles F.

Deapen

Dennis

Shnorhavorian

Margaret

Tompkins

Bradley J.

Simon

Michael

, and the Adolescent and Young Adult Health Outcomes and Patient Experience [AYA HOPE] Study Collaborative Group. 2012. “Positive and Negative Psychosocial Impact of Being Diagnosed with Cancer as an Adolescent or Young Adult.” Cancer 118(20):5155–5162.

Benner

Anne E.

Marlow

LuAnn S.

1991. “The Effect of a Workshop on Childhood Cancer on Students’ Knowledge, Concerns, and Desire to Interact with a Classmate with Cancer.” Children’s Health Care 20(2):101–107.

Bronfenbrenner

Urie

. 1979. The Ecology of Human Development: Experiments by Nature and Design. Cambridge, MA: Harvard University Press.

Bronfenbrenner

Urie

. 1986. “Ecology of the Family as a Context for Human Development: Research Perspectives.” Developmental Psychology 22(6):723–42.

10.

Bronfenbrenner

Urie

. 1994. “Ecological Models of Human Development.” Pp. 1643–47 in Vol. 4, International Encyclopedia of Education Oxford. 2nd ed., edited by T. Husén Postlehwaite

T. N.

Oxford, England: Elsevier.

11.

Cacioppo

John T.

Hawkley

Louise C.

2003. “Social Isolation and Health, with an Emphasis on Underlying Mechanisms.” Perspectives in Biology and Medicine 46(3):39–52.

12.

Chekryn

Joanne

Deegan

Marion

Reid

Jean

. 1986. “Normalizing the Return to School of the Child with Cancer.” Journal of the Association of Pediatric Oncology Nurses 3(2):20–24,34.

13.

Copen

Casey E.

Daniels

Kimberly

Vespa

Jonathan

Mosher

William D.

2012. “First Marriages in the United States: Data from the 2006-2010 National Survey of Family Growth.” National Health Statistics Report 49:1–21.

14.

Costa-Requena

Gema

Arnal

Rafael Ballester

Gil

Francisco

. 2015. “The Influence of Coping Response and Health-Related Quality of Life on Perceived Social Support During Cancer Treatment.” Palliative & Supportive Care 13(3):683–89.

15.

Davison

Tanya E.

McCabe

Marita P.

2006. “Adolescent Body Image and Psychosocial Functioning.” The Journal of Social Psychology 146:115–30.

16.

Centers for Disease Control and Prevention. 2021. “Chronic Diseases and Health Promotion.” Retrieved June 23, 2021. (https://www.cdc.gov/chronicdisease/index.htm)

17.

Engle

Jennifer M.

McElwain

Nancy L.

Lasky

Nicole

. 2011. “Presence and Quality of Kindergarten Children’s Friendships: Concurrent and Longitudinal Associations with Child Adjustment in the Early School Years.” Infant & Child Development 20(4):365–86.

18.

Gillen

Meghan M.

Lefkowitz

Eva S.

2009. “Emerging Adults’ Perceptions of Messages About Physical Appearance.” Body Image 6(3):178–85.

19.

Gillmor

Mickey

. 2001. “The Hospital: A Foreign Culture.” International Journal of Childbirth Education 16(1):18–19.

20.

Glasson

Joanna E.

1995. “A Descriptive and Exploratory Pilot Study into School Re-Entrance for Adolescents who have Received Treatment for Cancer.” Journal of Advanced Nursing 22:753–58.

21.

Gordijn

Ernestine H.

Koomen

Willem

Stapel

Diederik A.

2001. “Level of Prejudice in Relation to Knowledge of Cultural Stereotypes.” Journal of Experimental Social Psychology 37:150–57.

22.

Gray

Christine C.

Rodrigue

James R.

2001. “Brief Report: Perceptions of Young Adolescents about a Hypothetical New Peer with Cancer.” Journal of Pediatric Psychology 26(4):247–52.

23.

Husson

Olga

Zebrack

Bradley J.

Aguilar

Christine

Hayes-Lattin

Brandon

Cole

Steve

. 2017. “Cancer in Adolescents and Young Adults: Who Remains at Risk of Poor Social Functioning Over Time?” Cancer 122:2743–51.

24.

Iobst

E. A.

Ritchey

P. N.

Nabors

L. A.

Stutz

Ghee

Smith

D. T.

2009. “Children’s Acceptance of a Peer Who is Overweight: Relations among Gender, Age and Blame for Weight Status.” International Journal of Obesity 33:736–42.

25.

King

Sara

MacDonald

Amanda J.

Chambers

Christine T.

2010. “Perceptions of Healthy Children Toward Peers with a Chronic Condition.” Children’s Health Care 39:199–213.

26.

Kingery

Julie Newman

Erdley

Cynthia A.

Marshall

Katherine C.

2011. “Peer Acceptance and Friendship as Predictors of Early Adolescents’ Adjustment Across the Middle School Transition.” Merrill-palmer Quarterly 57(3):215–43.

27.

Klima

Tali

Repetti

Rena L.

2008. “Children’s Peer Relations and Their Psychological Adjustment: Differences Between Close Friendships and the Larger Peer Group.” Merrill-Palmer Quarterly 54(2):151–78.

28.

Lansu

Tessa A. M.

Cillessen

Antonius H. N

. 2012. “Peer Status in Emerging Adulthood: Associations of Popularity and Preference with Social Roles and Behavior.” Journal of Adolescent Research 27(1):132–50.

29.

Mattsson

Emma

Ringnér

Ljungman

von Essen

. 2007. “Positive and Negative Consequences with Regard to Cancer During Adolescence. Experiences Two Years After Diagnosis.” Psycho-Oncology 16(11):1003–09.

30.

Meltzer

Lisa J.

Rourke

Mary T.

2005. “Oncology Summer Camp: Benefits of Social Comparison.” Children’s Health Care 34:4305–14.

31.

Montgomery

Marilyn J.

2005. “Psychosocial Intimacy and Identity: From Early Adolescence to Emerging Adulthood.” Journal of Adolescent Research 20(3):346–74.

32.

National Cancer Institute. 2018. “Types of Cancer Treatment.” Retrieved April 22, 2018. (https://www.cancer.gov/about-cancer/treatment/types)

33.

Noll

Robert B.

LeRoy

Sarah

Bukowski

William M.

Rogosch

Fred A.

Kulkarni

Roshni

. 1991. “Peer Relationships and Adjustment in Children with Cancer.” Journal of Pediatric Psychology 16(3):307–26.

34.

Parker

Jeffrey G.

Asher

Steven R.

1987. “Peer Relations and Later Personal Adjustment: Are Low-Accepted Children at Risk?” Psychological Bulletin 102(3):357–89.

35.

Pascarella

Ernest T.

Terenzini

Patrick T.

1991. How College Affects Students: Findings and Insights from Twenty Years of Research. San Francisco, CA: Jossey-Bass Publishers.

36.

Pendley

Jennifer Shroff

Dahlquist

Lynnda M.

Dreyer

ZoAnn

. 1997. “Body Image and Psychosocial Adjustment in Adolescent Cancer Survivors.” Journal of Pediatric Psychology 22(1):29–43.

37.

Pini

Simon

Hugh-Jones

Siobhan

Gardner

Peter H.

2012. “What Effect Does a Cancer Diagnosis have on the Educational Engagement and School Life of Teenagers? A Systematic Review.” Psycho-Oncology 21(7):685–94.

38.

Roberts

Cleora S.

Turney

Mary E.

Knowles

Annette M.

1998. “Psychosocial Issues of Adolescents with Cancer.” Social Work in Health Care 27(4):3–18.

39.

Schultz

Kris Ann P.

Ness

Kirsten K.

Whitton

John

Recklitis

Christopher

Zebrack

Brad

Robison

Leslie L.

Zeltzer

Lonnie

Mertens

Ann C.

2007. “Behavioral and Social Outcomes in Adolescent Survivors of Childhood Cancer: A Report from the Childhood Cancer Survivor Study.” Journal of Clinical Oncology 25(24):3649–56.

40.

Seidah

Amélie

Bouffard

Thérèse

. 2007. “Being Proud of Oneself as a Person or Being Proud of One’s Physical Appearance: What Matters for Feeling Well in Adolescence?” Social Behavior and Personality 35(2):255–68.

41.

Vannatta

Kathryn

Garstein

Maria A.

Zeller

Meg

Noll

Robert B.

2009. “Peer Acceptance and Social Behavior During Childhood and Adolescence: How Important are Appearance, Athleticism, and Academic Competence?” International Journal of Behavioral Development 33(4):303–11.

42.

Warner

Echo L.

Kent

Erin E.

Trevino

Kelly M.

Parsons

Helen M.

Zebrack

Bradley J.

Kirchhoff

Anne C.

2016. “Social Well-Being among Adolescents and Young Adults with Cancer: A Systematic Review.” Cancer 122(7):1029–37.

43.

World Health Organization. 2018. “Health Topics: Noncommunicable Diseases.” Retrieved March 10, 2018. (http://www.who.int/topics/noncommunicable_diseases/en/)

44.

Zakin

David F.

1983. “Physical Attractiveness, Sociability, Athletic Ability, and Children’s Preference for their Peers.” Journal of Psychology 115(1):117–12.