1. Background
Cancer is a multifaceted disease that affects patients both physically and psychologically, significantly impacting their mental health (1, 2). According to estimates by the International Agency for Research on Cancer (IARC) in 2022, approximately 20 million new cancer cases were diagnosed globally, with 9.7 million cancer-related deaths. It is estimated that 53.5 million people were alive within 5 years of a cancer diagnosis; however, this rate varies depending on the type of cancer and geographic region. Cancer has become an increasing global challenge, with 1 in 5 people developing the disease during their lifetime, and approximately 1 in 9 men and 1 in 12 women dying from it. Data from the Global Cancer Observatory indicate that 10 types of cancer accounted for around two-thirds of new cases and deaths worldwide in 2022. Among these, lung cancer was the most commonly diagnosed (2.5 million cases, 12.4%), followed by female breast cancer (2.3 million cases, 11.6%) and colorectal cancer (1.9 million cases, 9.6%). Lung cancer also remained the leading cause of cancer mortality, responsible for 1.8 million deaths (18.7% of total cancer deaths) (3).
The effects of cancer on a family member can be substantial and negative for the entire family. Family involvement in caring for a patient with cancer can lead to changes in family functioning, roles, and stress distribution, negatively impacting the quality of life of family members (4). Furthermore, family caregivers face physical issues such as bodily pain, fatigue, and sleep disturbances, as well as psychological effects like depression, adjustment disorders, panic disorders, anxiety, and emotional reactions such as anger, hopelessness, and fear (5).
Among family members, spouses of patients with cancer may experience more psychiatric symptoms, including depression and anxiety, compared to the patients themselves. A cohort study involving over 3 million people reported a high risk of psychiatric disorders in the spouses of patients with cancer, indicating that they should be included in the monitoring and counseling process during the treatment of patients with cancer (6). The effects of men's cancer and their treatment and care processes on their wives can be categorized into six areas based on available sources: (1) Emotional and psychological pressure: Spouses of patients with cancer may experience higher levels of stress, lower health-related quality of life, emotional distress, and depression due to the cancer, symptoms, hospital admissions, and caregiving roles; (2) physical pressure: Female caregivers may experience weakened immune systems, reduced appetite, and high blood pressure due to their caregiving roles; (3) social impact: Spouses of patients with cancer may face social isolation and loneliness due to restrictions on their social activities; (4) unmet needs: Healthcare providers often fail to fully recognize the crucial role female caregivers play, which can lead to feelings of fear among caregivers (7); (5) gender differences: Female caregivers tend to report worse health compared to male caregivers and may have different needs and mental health statuses (8, 9); (6) impact on marital relationships: The process of cancer diagnosis and treatment may put pressure on the relationships between couples, potentially leading to divorce (8).
All these factors can influence the process of hope formation in the spouses of men with cancer. For instance, the experience of having cancer for men is often characterized by denial, anger, sadness, and fear, which can also affect their spouse's hope (10). Caregivers' hope is linked to their unmet needs, including health and informational needs, as well as occupational and social needs (11). Caregivers' hope is strengthened by trust in relationships with healthcare teams and the support provided by primary palliative care interventions (12) Meanwhile, the hope of caregivers, particularly the hope of spouses of men with cancer, plays a crucial role in the care and treatment process of the patients. Caregivers who feel hopeful are more likely to provide better care and support to patients, which can positively influence the patient's own experience of hope (13).
Snyder's definition of hope conceptualizes it in terms of goal-setting, planning, and motivation (agency). It is a positive motivational state that is based on an interactively derived sense of successful agency (goal-directed energy) and pathways (planning to meet goals) as well as finding alternative solutions to problems (14). This type of hope can currently be considered "specific hope", which involves having a clear vision of what one is hoping for and taking action to achieve it. This type of hope contrasts with "generalized hope", which is not specific to any particular situation or context and is a general sense of optimism and positive expectation for the future. "Multidimensional hope" is also a combination of these two types of hope (15).
Indeed, the factors that intervene and influence hope in individuals encompass various dimensions and elements. Hope is considered a global phenomenon that can be examined from cognitive, emotional, behavioral, social, religious, and value-based dimensions (16, 17). Additionally, several interpersonal mediators play a role in fostering hope in individuals. These interpersonal mediators include self-esteem, active coping, and perceived social support (18). Self-efficacy is another important construct influencing hope, as individuals with high self-efficacy are more likely to generate hope and engage in goal attainment (19). Agency Thinking, which refers to an individual's perceived ability to pursue goals actively, and Pathway Thinking, which refers to an individual's perceived ability to create ways to achieve goals, are two sub-dimensions of hope that contribute to mental well-being (20).
Similarly, the factors influencing hope in the spouses of men with cancer are affected by various elements. Research has shown that the diagnosis of breast cancer in a spouse can lead to experiences of devotion, vulnerability, struggle, hope, and heroism in spouses. Furthermore, hope in the spouses of individuals with cancer is associated with psychological variables such as depression, distress, coping, and post-traumatic growth (21, 22). The level of hope in spouses is also influenced by factors such as the family’s net income, awareness of the disease, perceived family support, and the presence of physical symptoms and emotional states like anxiety and fear (23). These findings highlight the importance of addressing the psychological well-being and supportive needs of spouses to enhance hope in this group (24).
The life experiences of spouses of men with cancer have been the subject of limited research. A few studies have examined the experience of hope and the lived experiences of women caring for their husbands with cancer. For instance, a study in Zambia explored the experiences and coping strategies of women in caring for their afflicted husbands (25). Additionally, another study examined the hopes and challenges of rural female caregivers of individuals with advanced cancer, focusing on providing insights into the challenges and hopes of these caregivers (26).
Overall, among the reviewed studies, no study specifically addressed the foundations of hope formation in the spouses of men with cancer. The reviewed studies primarily focused on hope models in patients with cancer, the impact of cancer on spouses, the role of hope in treatment success, and the levels of hope in patients with cancer. Given the lack of research on experiences related to hope concerning the foundations of hope formation in this group and considering the importance of extracting these experiences to better understand the psychological conditions of these individuals, this study was conducted.
2. Objectives
This study was conducted using a qualitative approach and conventional content analysis method. The qualitative approach can provide researchers with deep insights into the understanding and experiences of individuals. This method focuses on life experiences, interpretation, and the concepts that patients have been exposed to. Content analysis is a qualitative method for linking data to the main subject, and its final product consists of the concepts and categories forming the studied topic.
3. Methods
3.1. Participants
The participants in this study were selected from women whose husbands were diagnosed with cancer and who met the five entry criteria: (1) Their husbands were undergoing treatment, (2) their husbands were not in the terminal stage of the disease, (3) they were aged between 20 to 55 years, (4) they had been married for at least five years, and (5) they had sufficient ability for effective verbal communication. Also, participants were chosen from caregivers of patients with cancer referred to Firoozgar Hospital in Tehran. They were chosen using purposive sampling and face-to-face interviews continued until data saturation was reached, involving a total of 11 participants.
3.2. Data Collection and Analysis
Data were collected through semi-structured interviews from September 2022 to November 2023. All interviews were conducted face-to-face in a private and quiet setting to ensure confidentiality and comfort for participants. The duration of the interviews ranged from 60 to 90 minutes. Data saturation was achieved when no new themes or subthemes emerged from the data, which occurred after the 11th interview. The semi-structured interviews included questions that encouraged participants to freely and voluntarily share rich and in-depth information about their experiences, perceptions, and viewpoints. Additionally, the researcher used follow-up questions when necessary to clarify ambiguities and delve deeper into the information provided. Some of the interview questions included: "Can you describe your experiences and conditions during this period?", "What experiences of hopelessness did you have at the onset and during the progression of your husband's illness?", "If you had experiences of hope, can you tell me when they started and what those experiences were?", "How did you cope with feelings of hopelessness?".
For data analysis, Graneheim and Lundman's method was used (22), starting with the verbatim transcription of all interviews, which were read multiple times to gain a comprehensive understanding of the text. The interviews were segmented into meaning units, summarized, and assigned codes. In total, 116 initial codes were identified. All extracted codes were reviewed by the researchers and were grouped into initial categories based on their similarities and connections after reaching consensus within the research team. Through continuous comparison of the extracted concepts, subcategories and main categories were systematically formed to ensure analytical rigor.
3.3. Criteria for Trustworthiness of Data
To ensure the trustworthiness of the data, the criteria proposed by Lincoln and Guba, which include credibility, dependability, transferability, and confirmability, were utilized (27). For credibility, the data were reviewed and confirmed by three experts in qualitative research. To enhance the validity of the findings, maximum variation sampling was employed. To adhere to the principle of confirmability, the research team ensured that the theoretical and personal values of the researchers did not influence the analysis and extraction of results. All codes and themes were reviewed and confirmed under the supervision of a supervisor.
For dependability, the data were independently coded by two members of the research team, achieving high agreement. To meet the criterion of transferability, the data were reviewed and confirmed by three qualitative research specialists who had not previously participated in the research process. Additionally, the extracted codes were presented to the participants, who confirmed the similarity of the extracted concepts with their own experiences.
To adhere to the principles of reflexivity — defined as a set of practices through which researchers consciously critique and evaluate the effects of their subjective interpretations and potential biases on data analysis (28), we employed strategies proposed by Graneheim and Lundman (29) to enhance the trustworthiness of qualitative research findings. These strategies included investigator triangulation (team discussions and collaborative review of data), providing a transparent description of the analytical process, and using direct quotations from participants to demonstrate the connection between data and findings. Additionally, member checking — a method of participant validation recommended by Lincoln and Guba (27) — was utilized to support the principles of reflexivity and ensure the accuracy and credibility of the findings.
3.4. Ethical Approval
All stages of the research were conducted following the ethical certification number IR.USWR.REC.1398.194 from the University of Rehabilitation Sciences and Social Health and adhered to the relevant regulations in planning and implementation. This study is part of a broader research project within the framework of the first author's doctoral dissertation.
4. Results
Table 1 shows the demographic and cancer characteristics of participants in the study. Additionally, Demographic and Cancer Characteristics of Spouses of Women Participants in this study are presented in Table 2.
| Age Range | 29 - 55 (Mean 37.5) |
|---|---|
| Educational status | One Elementary, 1 high school, 2 associate degree, 3 bachelor, 4 master’s degree |
| Psychological service history | Six with history, 5 without history |
| Parental status | Six without children, 5 with children |
Demographic Characteristics of Participants
| Age Range | 29 - 60 |
|---|---|
| Educational status | Two high school, 6 bachelor's, 3 master's degrees |
| Type of cancer | One lung cancer, 3 prostate cancer, 2 brain cancer, 2 leukemia, 2 colon cancer, 1 skin cancer |
| Number of years with cancer | Lung cancer (for 1.5 years and then died), prostate cancer (with an average of 1.5 years), brain cancer (with an average of 3 years), leukemia (with an average of 1 year), colon cancer (with an average of 1.5 years), skin cancer (for 2 years) |
Demographic and Cancer Characteristics of Participants
Moreover, the data analysis yielded one main category — termed "Intrapersonal Foundations" — that represents the foundations of hope formation. This main category, along with its subcategories and initial categories, is presented in Table 3.
| Main Categories and Subcategories | Initial Categories |
|---|---|
| Intrapersonal foundations | |
| Acceptance and adaptation | (1) acceptance, (2) adaptive and patient coping |
| Transformation and meaning reconstruction | (1) redefining cancer and its aspects, (2) reconstruction of life meaning, (3) making sense of care, (4) understanding possibilities and opportunities, (5) metaphorical and cultural meanings |
| Empowerment and self-determination | (1) self-discovery and Self-creation, (2) freedom and determination of destiny, (3) power and action |
| Manifestation of confrontation will | (1) rising up and coping, (2) integration of self and family |
The Main Category and Subcategories of the Research
4.1. Intrapersonal Foundations of Hope
The intrapersonal foundations of hope refer to the cognitive and emotional processes within an individual that contribute to the formation and expansion of hopeful attitudes, beliefs, and behaviors. These factors are defined within four subcategories: "Acceptance and Adaptation", " Transformation and Reconstruction of Meaning", "Empowerment and Self-Determination", and "Manifestation of the Will to Confront".
4.1.1. Acceptance and Adaptation
Acceptance and adaptation in this study involved the conscious acknowledgment of personal experiences and the ability to adapt and undergo cognitive restructuring without attempting to change or control them when faced with life's challenges. This promotes the necessary psychological changes to cope with the ebbs and flows and "the uncertainties of life." These changes, based on acceptance and adaptation, can be explained in two primary categories.
4.1.1.1. Acceptance
According to the research findings, acceptance in life means altering one's perspective and developing a hopeful outlook to view the natural course of life to impact it positively. Acceptance also encompasses the stages of transitioning from the initial trauma to the acknowledgment of life's realities and challenges and facing them. This process requires a shift in attitudes and thoughts. Specifically, acceptance manifests as the need to focus on changing situations rather than resisting them for better management and finding ways to cope. In this regard, Participant 4 noted: "Initially, I couldn't accept the sudden shock that cancer brought us; it was very hard. But gradually, over time and through talking with others, my outlook on hope and standing strong improved, and I was better able to accept and move past the shock".
4.1.1.2. Adaptive and Patient Coping
The main aspects of adaptive and patient coping in this group included balancing the care for one's spouse with self-care, maintaining equilibrium in relationships with family members and others, having active communication with a support network and receiving help from others, managing patience over time, preventing dispersing of the family, enduring hardships without separating from the ill spouse, adapting to life changes, understanding the necessity of effective coping with difficult conditions, preparing the mind for facing uncertainties, and managing negative thoughts and emotions, especially fear, worry, and anger while employing positive thoughts and mental detachment techniques. For instance, Participant 11 stated: "First of all, they need to be patient. Patience is necessary to let time pass. Without patience, their life falls apart, they separate, and other problems arise. Future and worse problems must be prevented in advance".
4.1.2. Transformation and Reconstruction of Meaning
Based on the findings, "transformation and reconstruction of meaning" refers to the process of changing and reconstructing cognition, the meaning system, and the purpose of life in the face of existing challenges and events, which includes five primary layers, each of which focuses on different aspects of this process: Redefinition of cancer and its aspects, reconstruction of life meaning, making sense of caregiving, understanding possibilities and opportunities, and cultural and metaphorical meaning-making.
4.1.2.1. Redefining Cancer and Its Aspects
Research showed that the theme "Redefinition of Cancer and Its Aspects", signifies providing a new and adaptive perspective on cancer, shifting it from an "unsolvable problem" to a "challenge with solutions". This theme views cancer from various angles, including: Perceiving cancer positively as a catalyst for personal and spiritual growth, a benevolent nudge from God, or seeing it as an alien invader incompatible with life. This perspective highlights cancer as an imposing and totalizing phenomenon with anti-individual, anti-spontaneity, and anti-freedom effects, which renders not only the patient but all family members passive. This characteristic of cancer is referred to as the "cancer tradition". In this regard, Participant 5 remarked: "It felt like cancer, similar to dictatorial and authoritarian parents, was forcefully embedding its strong and tyrannical claws into my destiny and individuality". Participant 3 noted: "This intrusion, bullying, and all-encompassing greed of cancer, in my opinion, is the damn cancer tradition".
4.1.2.2. Reconstruction of Life Meaning
Understanding the "necessity of perspective reconstruction" based on "acceptance of life's nature", "separating life from catastrophe", and focusing on the "priority of life in the current situation", which is saving life from cancer as an imminent threat, plays a crucial role in reframing the meaning of life for this group. Additionally, viewing the nature of life as a "scene of struggle and hardships, and a realm of continuous change and impermanence" as opposed to the destructive and tyrannical nature of cancer, and finding new meaning in life through coping with calamity, are significant aspects of reconstructing the meaning of life. For instance, Participant 1 mentioned: "I thought about how this is the nature of life, and what choice do we have other than to continue? Otherwise, everything turns into a graveyard, and one loses oneself. But I want to live and to live, I must constantly challenge its ups and downs".
4.1.2.3. Making Sense of Care
Within this group, the concept of care — which plays a role in shaping hope — can be described as a purposeful, self-directed activity rooted in individual decision-making. Rather than being imposed by cancer, care serves as a platform for the emergence of fundamental personal values such as autonomy and agency toward taking responsibility and making an impact on one's life. Additionally, caregiving is not limited solely to the patient but also extends to the family, thereby becoming a crucial priority in contemporary life and motivating actions to overcome hardships. For instance, Participant 1 remarked: "Now I had a new goal to focus on, which was caring for my husband. During that time, I felt good about taking care of my husband; it allowed me to attend to my home, my husband, and myself without other stress. Even if the situation was worse, this goal motivated me to get through it".
4.1.2.4. Understanding Possibilities and Opportunities
Various aspects of this concept within the studied group, which play a role in shaping hope, can be described as follows: Understanding the possibility of effectively and constructively utilizing events and new opportunities to create changes fosters motivation and hope in these individuals. "Monitoring situations and events to find any constructive opportunity to create change" instead of remaining passive and depressed is essential. Participant 5 mentioned: "We should always look around and be on the lookout for new opportunities to create change. Well, these things bring hope".
4.1.2.5. Metaphorical and Cultural Meanings
Research findings indicated that when individuals face difficult and challenging situations, metaphorical and cultural meanings can provide them with hope through "interpretations based on metaphorical comparisons". These interpretations guide individuals to stories, myths, and symbols that represent resilience, strength, salvation, leadership, and hope in the face of life's challenges and adversities. For instance, Participant 4 mentioned: "We are now like the cypress tree; maybe we bend under the storm of calamity, but we do not break, just like Iran. Many devastating events like storms and cancer have struck Iran, but it still stands. I am also like the cypress of Iran, deeply rooted and strong, able to stand and resist calamity. This gave me strength".
4.1.3. Self-Empowerment and Self-Determination
Self-empowerment and self-determination refer to an active, creative, and autonomous process where individuals, through a better understanding of themselves, take deliberate actions to recreate their sense of self based on previous experiences and actively shape their own destiny. This subcategory is composed of three primary categories.
4.1.3.1. Self-Discovery and Self-Creation
This concept in the studied group involves an action based on a new awareness of one's own human possibilities and potentials, manifesting as an inner strength to create changes. This transformation is framed as an internal struggle, separating the conscious and powerful aspect of oneself from the weak, hopeless, and passive self, providing a new stance for moving towards creating individuality and a "free self" to counteract existing constraints and pressures, and shaping one's destiny by their own hands. For instance, Participant 5 mentioned: "At first, I thought I was seeing a new version of myself, but I realized that I wasn't just seeing it; I was actively creating my new self through my actions and efforts. Someone who fights for their destiny and wants to actively shape it themselves. This made me feel free".
4.1.3.2. Freedom and Determination of Destiny
According to the findings, individuals undergoing their spouse’s illness and treatment faced a primary challenge: The struggle for freedom and the determination to shape their destiny against the tyranny of cancer and the fate it imposes. Here, freedom is understood as a dual concept. It refers both to inner freedom — from the unreal aspects of the self shaped by past experiences and parental upbringing, leading to a conscious, self-determined individuality — and to external freedom, which means liberation from cancer’s totalitarian interventions in personal and family life through deliberate self-determination. For example, Participant 5 stated: "This freedom came after the changes within me, which meant freedom from the weak aspect that wasn’t my true self and was submissive and nurtured by my authoritarian parents. But now I am free to determine my destiny and build the individuality I desire".
4.1.3.3. Power and Action
Power, as outlined by the findings of this study, encompasses not only an awareness of one's innate potentials but also an understanding of how to leverage these potentials effectively. It involves choosing a personal path, asserting influence over one’s life and destiny, and confronting the narrative of cancer. The expression of power also requires courage, pragmatism in self-creation, and resilience in the face of adversity. For example, Participant 2 shared: "My power and strength lie in the fact that I can impact my life and choose my own path despite all the pressures and difficulties. Without the right to choose, we would be nothing".
In terms of action, three key aspects emerged from the categorization of meaning units:
(1) Self-based aspect: This involves activating one’s potentials and creating an authentic, impactful version of oneself, a self-driven act (as opposed to something forced or imposed). It reflects the individual’s self-expression in life.
(2) Goal-based aspect: This focuses on interventions aimed at achieving desired outcomes and personal goals.
(3) Outcome-based aspect: This includes the experience of a sense of being, a dynamic will, a feeling of empowerment, inner satisfaction, and hope. For example, Participant 3 remarked: "Some might say that destiny is in God's hands and we can only have a small impact on it, but I believe we can create our own destiny, and creating means taking action".
4.1.4. Manifestation of the Will to Fight
According to the findings, the manifestation of the will to confront refers to the emergence of the will to combat cancer through a series of actions undertaken by the individual and their family to effectively fight this disease and its negative impacts. This subcategory is composed of two primary categories: "Rising and Confronting" and "Integration of Self and Family".
4.1.4.1. Rising up and Coping
This process, based on the theme of related meaning units, is described in three categories: (1) Understanding and accepting a confrontational situation: This involves recognizing and accepting being in a crisis state. As Participant 3 noted: "We accepted that we are in a war-like, crisis situation and must accept this new form of life until the crisis is resolved"; (2) creating a new center of agency: This confrontational state includes efforts to establish a new center based on agency, a desire for freedom, considering the possibilities of victory, and organizing against the passive and paralyzing nature of cancer. As Participant 3 stated: "I realized that in this frightening world, which truly paralyzes and makes one passive, one must strive, take action, and not become paralyzed, thereby rising against the center of suffering and fears"; (3) developing combat and coping strategies: This includes the development of strategies to fight and cope with the situation. For instance, Participant 3 mentioned: "Cancer may attack just one person, but the whole family and all aspects of our lives are affected by my spouse’s cancer. We are in a war-like, crisis situation and must respond with activities that match this state".
4.1.4.2. Integration of Self and Family
The integration of self and family in the face of cancer refers to creating and strengthening connections and solidarity among family members when confronting the disease. This involves understanding and accepting the unity of the self, family, and patient in facing the challenges of cancer, adapting to the cancer treatment process as a collective family struggle, and approaching the battle against cancer on multiple, unified fronts. Additionally, this concept encompasses viewing oneself and the family as a cohesive unit, working together to maintain survival and mutual interests, accepting and enhancing the current life for the well-being of both the individual and the family, and feeling a responsibility toward the future of the children. For example, Participant 10 stated: "My connection to life was through my children, ensuring their future wouldn't be ruined by my shortcomings. I had a responsibility toward them. I had to have hope".
5. Discussion
The aim of this study was to explain the formation of the foundations of hope in the spouses of men with cancer in Iran. One main concept extracted includes the intrapersonal foundations of hope, which is discussed below. However, it should be noted that the experiences of spouses of men with cancer have not been widely studied, and few studies have examined the experience of hope in this group.
5.1. Intrapersonal Foundations of Hope
5.1.1. Acceptance and Adaptation
As previous studies have reported, hope is associated with various intrapersonal and psychological factors. The findings of the present study regarding the role of acceptance in fostering hope align with those of Kodba-Ceh et al. (30), who reported that hope is supported by the acceptance of uncertainties. This is also consistent with the findings of Rosario-Ramos et al. (31) and Bigi et al. (13), who reported that acceptance positively impacts the hope of caregivers of patients with cancer. However, based on the findings of the present study, acceptance — as a continuous cognitive-behavioral process in life — entails understanding and accepting stressful realities, confronting them, and transitioning through difficult conditions to reduce their negative impact on the individual, particularly when the individual cannot directly control their spouse’s illness.
Additionally, the present study’s findings on the role of adaptive and patient coping in shaping hope within this group are consistent with those of Sun et al. (32), who examined and reported the role of adaptive coping in the psychological well-being and resilience of caregivers. The present study’s findings also align with those of Opsomer et al. (33), who indicated that patience enables caregivers to adopt realistic yet hopeful attitudes. According to the findings, adaptive and patient coping, which forms the necessary foundation for fostering hope in this group, depends on creating a balance in each of the following areas: Various roles and associated functions, considering positive future possibilities alongside accepting negative uncertainties, enduring inevitable hardships while striving to effectively cope with difficult conditions, managing negative thoughts and emotions while generating positive thoughts and emotions, and separating oneself from the problem while viewing oneself as part of the solution.
5.1.2. Transformation and Meaning Reconstruction
According to the present study, individuals undergo a process of transformation and meaning reconstruction by revisiting the complexities of their experiences, gaining new perspectives, and reshaping their understanding of suffering, themselves, and the world around them. This ultimately fosters resilience and hope. In this context, redefining cancer is crucial, as it creates the necessary space for new goal-setting and action. These findings align with those of Azizi et al. (34), who reported that hope is associated with finding meaning in life-threatening situations. They are also consistent with the findings of Harvey and Berndt (35), who reported that facing and dealing with a traumatic event such as cancer in caregivers can lead to "post-traumatic growth" (PTG), including improvements in personal strength, appreciation of life, and new opportunities for the future.
A novel concept introduced in the present study in the process of redefining cancer is the "cancer tradition", which focuses on the impacts of cancer on both the patient and their family. Therefore, alongside treating cancer, the primary goal of caregivers' confrontation in fostering hope should also include combating this tradition. Additionally, there is a need to reconstruct the meaning of life within this group, which can be described as a process involving changing and re-evaluating one’s outlook on life and related motivations in the face of cancer and its associated traditions.
Furthermore, one aspect of transformation and meaning reconstruction in the present study involved making sense of caregiving. This aligns with Ahn et al. (36), who reported that meaning-making for some caregivers might involve finding hope and meaning in their interactions with the patient, caregiving activities, or spiritual beliefs. According to the findings, meaning-making in caregiving is a complex, multifaceted process that involves understanding and interpreting the concept and act of caregiving in a way that creates a sense of belonging to the caregiving role, goal-setting, and agency through it. In this group, the object of care extends beyond the patient to include the family, thus becoming a crucial and primary goal in the individual’s life, motivating actions to overcome hardships.
These findings are consistent with Snyder et al. (14), who conceptualized hope in terms of goal-setting, planning, motivation, and agency. The present study also highlights a novel aspect in the formation of hope based on meaning reconstruction. Research literature does not directly address the impact of metaphors and narratives on hope in caregivers of patients with cancer. Narrative therapy suggests that hope lies in the stories individuals use to make sense of their lives, and therapy can help reconnect them with hopeful stories (37). According to this study, metaphorical and cultural meaning-making is a process that uses metaphorical comparisons, symbolic terms, and mythological and historical stories to interpret and explain deeper concepts and meanings. This helps individuals gain a better understanding of the world around them and develop deeper, meaning-related connections around specific topics. However, the specific impact of metaphors, symbols, and narratives on hope in this group requires further research and evidence.
5.1.3. Empowerment and Self-Determination
In the present study, three concepts — "Self-Identification and Creation", "Freedom and Determination of Destiny", and "Power and Action" are emphasized as components of empowerment and self-determination in the spouses of men with cancer. "Self-identification and Creation" can be described as a dynamic and exploratory process centered on the principle of confrontation and forming a new stance. "Freedom and Determination of Destiny" also implies a kind of confrontation between two things. In both, the concepts of individuality, freedom, and agency against coercion and pressures are embedded. It can be concluded that hope in this group is highly dependent on forming "dialectical mental spaces", which result in an amalgamation of power and action. Power and action are reciprocally related and act as two essential elements in the process of change and determining one's destiny, leading to inner satisfaction and hope. "Power as a catalyst for action" and "action as an expression of power" reinforce each other simultaneously, forming a positive cycle. The theme of "Power and Action", according to the findings of this study, aligns with Snyder's theories on hope. In summary, scattered studies have addressed topics such as reframing one's caregiving identity and discovering ways to assert oneself (38)and the impact of self-efficacy and agentic thinking on finding hope and activating oneself in the face of existing pressures (19, 39), which can align with the findings of the present study.
5.1.4. Manifestation of the Will to Confront
"Rising and confronting" cancer involves the emergence of a powerful will, manifested through the conscious selection of a set of actions aligned with the existing crisis conditions that an individual undertakes to combat their spouse’s illness, its associated traditions, and its effects. This leads to the realization of hope and positive change in life. The findings of this study in this area are consistent with those of Bigi et al. (13), who reported that caregivers perceive themselves as effectively acting through a combination of caregiving activities and roles, including fighting and being present for the cancer-stricken family member. This resilience and joint battle against cancer profoundly impact the hope of caregivers of patients with cancer.
Additionally, "Integration of Self and Family" in the face of cancer involves viewing oneself and the family as a cohesive unit in maintaining survival and mutual interests. For those with children, concerns about their future foster a deep connection to current life and a commitment to not abandoning the ill spouse. These findings align with those of Bigi et al. (13), who reported that involving multiple family members enhances overall caregiving coordination, as well as with Nierop-van Baalen et al. (40), who indicated that family involvement has a positive impact on the hope of its members.
Ultimately, it can be said that one of the major achievements of this study is its comprehensive analysis of the "intrapersonal foundations of hope formation" in the spouses of patients with cancer. This study introduces a novel approach and framework, moving beyond traditional perspectives on caregivers' hope. Additionally, it presents the concept of "cancer tradition", emphasizing the oppressive and destructive impacts of cancer on individuals and their families.
The study highlights the importance of "confrontation", rooted in the dynamic interaction between personal free will and the destructive tradition of cancer. It explores new dimensions of hope and resilience, focusing on individual will, self-creation, and self-determination. The use of metaphors, allegories, and cultural meanings adds a sociocultural dimension rarely explored in similar studies.
Furthermore, the study uniquely emphasizes the roles and experiences of spouses, underlining the importance of family cohesion in cancer research.
The findings provide a theoretical framework for future research on hope, coping mechanisms, cultural narratives, family cohesion, and meaning-based interventions to improve caregivers' quality of life. They can also inform counseling programs and psychotherapeutic interventions to strengthen hope and resilience among spouses of patients with cancer, enhancing support systems and training healthcare teams to address families' psychological and emotional needs.
5.2. Limitation
Although the study provides data on the types of cancer affecting the participants’ spouses (Tables 2 and 3), it does not analyze the varying psychosocial impacts of different cancer types, which may limit the specificity and generalizability of the findings. In addition, participants' emotional distress during interviews may have influenced their responses, potentially affecting the accuracy of the data collected. Furthermore, the absence of longitudinal data limits the ability to examine how hope formation evolves over time or in response to illness progression. The study's focus on the Iranian cultural context and a small qualitative sample may restrict the generalizability of the findings to broader populations or other cultural settings. Finally, the reliance on self-reported interviews provides valuable insights but may introduce biases related to memory recall and subjective interpretation.
5.3. Conclusions
This study identified four key intrapersonal foundations of hope in the spouses of men with cancer:
Acceptance and adaptation: Developing a positive outlook by accepting life's challenges and balancing caregiving with self-care.
Transformation and reconstruction of meaning: Redefining cancer as a manageable challenge, reconstructing life’s purpose, and leveraging cultural and metaphorical meanings for resilience.
Empowerment and self-determination: Cultivating self-awareness, regaining autonomy, and taking active steps to shape one’s destiny despite adversities.
Manifestation of the will to confront: Strengthening family unity and creating actionable strategies to cope with and combat cancer’s impacts.
The central theme of these foundational elements is the concept of confrontation, which arises in individuals’ minds between themselves and their attachments — such as personal and family life, destiny, and individual freedom — against cancer and its totalitarian, destructive, and imposing tradition. This confrontation prepares individuals to mobilize both internal and external resources to manage the situation and its challenges.
