Are some more equal than others? Social comparison in self-management skills training for long-term conditions

Background: Social comparisons influence self-evaluation and social and psychological adjustment to illness but are under-explored in relation to self-skills training group situations. Methods: A longitudinal qualitative study embedded within an RCT of a national programme of lay led self-care support in England (Department of Health, 2001). In-depth interviews were undertaken with a purposeful maximum variation sample of recruits. Data were analysed thematically. Three key themes emerged highlighting (1) the experience of group participation and interaction, (2) the process and (3) function of social comparison. Results: Data highlight the salience of social comparison as an underlying feature of the group dynamics of self-care skills training. The nature, dimensions and scope of social comparisons extend beyond the cognitive states and dimensions traditionally forming the focus of social-psychological approaches to social comparison to include wider dimensions including entitlement to resources. The results confirm the tendency to make positive comparisons that result in beneficial self-evaluations. However, positive comparisons allow respondents to present themselves as socially and morally worthy, which may act to mask the identification of appropriate need and inequalities. Conclusion: Social comparisons function both as an accurate representation of internal cognitive states but also constitutes identity work involving competing values and moral requirements. We show that even those who report significant needs will sometimes portray themselves in a way that suggests positive social comparisons, which fit with a rationed and morally prescriptive and acceptable view of entitlement to NHS services. Such insights suggest that social comparisons in initiatives such as the EPP may be beneficial for some but exacerbate rather than alleviate health inequalities in long-term condition management for others.