Hope-Promoting Strategies: Perspectives of Iranian Women with Breast Cancer About the Role of Social Support

1. Background

Hope can be regarded as a multi-dimensional phenomenon with various context-based definitions. Although there is no consensus among researchers regarding the definition of hope, the positive nature of hope has been accentuated and approved in the literature (1).

Furthermore, the constructive and significant role of hope in human life in general and human health promotion, in particular, has been well-recognized (2). Additionally, loss of hope has been proved not only to threaten the physical and psychological health of patients with cancer, but also to affect the survival of these patients (3).

Hence, promotion of hope can be specified as one of the effective strategies to achieve health-related goals and improve the quality of life in patients with chronic and life-threatening diseases such as breast cancer (4).

In Iran, breast cancer is the most common cancer in women and has an annual incidence rate of over 10,000 cases. Moreover, its prevalence in Iranian context is one-fifth to one-sixth higher than that of the European and American countries. Although the survival rate of Iranian women with breast cancer has increased to 71% over recent years, the incidence age of this disease, which is about 48 years old in Iran, still remains a serious challenge. The onset of the mentioned incidence age observed among Iranian women with breast cancer is one decade earlier than that of their counterparts in other countries (5).

Furthermore, as women within this age range are not only committed to play their family roles, but also tend to play a number of various social roles; cancer may lead to a vast number of changes in their life (6).

Hence, it seems that the presentation of an array of strategies to promote a due degree of hope in patients diagnosed with cancer through the nursing process would be of great value to meet health promotion objectives (7). However, it is crystal-clear that provision of hope-promoting strategies may not be feasible without consideration of the social context in which hope emerges (4).

A number of studies in this respect have revealed that social support is one of the most important social factors influencing hope that in many cases may act as an external buffer factor for patients with cancer, who always seek support (8).

In addition to metastasis, pain, and lower self-esteem, patients with breast cancer experiences loss of hope due to the traumatic nature of cancer. Undergoing the mentioned experiences accentuates the necessity of receiving social support, especially from a network of supportive resources (6).

A review of the literature indicates that the relationship between hope and social support and the role of social support in promoting hope in women with breast cancer have been regarded as controversial issues in medical research. While the number of studies has specified that social support is the source of hope for women with breast cancer (4, 9-13), and there is a positive relationship between hope and social support (6, 8, 14-16), only one study has been stated the indirect relationship between the two mentioned concepts (8) and no study was found on the understanding of women with breast cancer in the context of the role of social support in promoting hope.

As hope and social support are community-based issues influenced by social and cultural factors, it seems that their thorough examination in different countries with various cultures may shed more light on the exact perception of hopefulness provided by social support (6).

Social relationships in general and family relationships, in particular, are highly emphasized in Iran due to the particular context of Iran. Furthermore, the role of families in promoting their members’ health and taking care of patients with cancer seems to be of great significance in the Iranian community (17).

2. Objectives

This study aims at addressing the perception of Iranian women with breast cancer regarding the role of social support in promoting hope in Iran as a less touched-upon context. Obviously, the specification of the underlying social support sources effective in promoting hope in women with breast cancer can help nurses in delivering hope-based care.

3. Methods

This qualitative study was conducted, using conventional content analysis to answer this research question: “What is the perception of Iranian women with breast cancer from the role of social support in promoting hope?” which can identify of the role of social support in promoting hope in women with breast cancer.

In this study, 17 eligible women with breast cancer were selected following purposive sampling with consideration of the maximum variation in the selected sample.

Inclusion criteria for participants in the study were age older than 20 years regardless of the type of treatment, stage of disease, and presence or absence of metastasis, and no prior history of psychiatric disorders according to their self- declaration.

Purposive sampling was performed from the patients with breast cancer in the hospitalized and outpatient departments of Shohada-e-Tajrish Hospital of Tehran (capital of Iran) affiliated to Shahid Beheshti University of Medical Sciences as referral center of patients with cancer from around the country. To address sampling adequacy (18), data saturation was attended to in the study. When data presented by 16 participants were analyzed, data saturation was achieved. However, one more participant was interviewed to ensure that no new data will be added to the already-obtained data.

To collect data, in-depth semi-structured interviews were conducted, using an interview guide.

The time allocated for each interview was 30 to 60 minutes with an average of 45 minutes.

Furthermore, two telephone interviews, each lasting for a maximum of 10 minutes, were conducted with two participants to clarify their demographic and clinical characteristics.

During the interviews sessions, which were conducted on the bedside of hospitalized patients and at the clinic of Shohada-e-Tajrish Hospital with outpatients, the participants were first asked to introduce them and briefly describe their disease. Then, they were asked an open question. “What are your plans for the future in the current situation?” Next, based on the participants’ response, the following questions were asked: “What do you do to achieve the goals you have for the future?”, “What resources do you use to achieve these goals?”, “In what circumstances, do you feel that reaching future goals is possible for you?”

In addition to the mentioned follow-up questions, a number of probing questions such as: “Give me an example” and “Do you want to add anything else?” were asked to extend the participants’ answer, break their silence, or avoid any distractions from the main objectives of the study.

Application of the follow-up and probing questions supported the continuation of the responses provided over the interview session.

During the interview session, on some occasions in response to participants’ emotional burden posed by cancer experience, the interviewer allowed them to express their feelings to the extent that does not damage. Participants’ responses over the interview were audio-recorded with their permission.

In order to analyze the audio-taped interviews, the first step was transcribing the interview data, which required careful and persistent listening. However, it must be mentioned that data analysis occurred concurrently with data collection until the end of the study. After the initial verbatim transcription, conventional content analysis with the application of Graneheim and Lundman approach was used to analyze the obtained data of the study (19). A list of the codes was provided and reviewed after extracting the semantic units. Moreover, the obtained codes were compared with one another with a constant comparative analysis method, which led to ongoing abstraction and reduction after the determination of the similarities and differences in meaning. After identifying and labeling codes, it was time to put them into categories; finally, the codes were categorized into the subgroup, groups, and finally, a theme emerged.

In this study, Lincoln and Guba criteria including dependability, credibility, confirmability, and transferability were used to assess study trustworthiness.

Credibility criterion was fulfilled with continuous engagement with participants and a thorough examination of data and analysis procedure to expand the depth and breadth of information. Moreover, to establish credibility criterion, member checking in which the data, interpretations, and conclusions are shared with the participants was used. Hence, the findings were randomly sent to two participants by email and their proposed amendments were used in the final explanation of the phenomenon.

In addition, participants affirmed that the presented findings reflect their personal experience.

To meet the confirmability criterion, the participants’ statements were either explicitly quoted or implicitly presented in the study, which indicates that the provided findings are rooted in the obtained data. Moreover, peer checking, which also enhanced the dependability criterion, was performed to ensure rigorous and continuous scrutiny of the study process. To perform peer checking, 5 faculty members at Shahid Beheshti University, and 2 faculty members at two other Tehran universities of medical sciences audited the process and presented findings to enhance the dependability criterion.

Rich description of the research boundaries, limitations, context, in-depth interviews, suggestions for future research, implications for clinical performance, and the applied sampling procedure promoted transferability of the presented findings. Although the main objective of qualitative studies is not generalizability, healthcare professionals can take advantage of the findings of this study to offer better services in similar situations.

Ethical approval from the Research Ethics Committee Shahid Beheshti University (IR.SBMU.PHNM.2015.272), legal permission from authorities of Shohada-e Tajrish Hospital, and participants’ informed written consent to collect data and conduct interviews were obtained at the onset of the study. Some of the ethical principles that the researchers strictly committed to were the mere utilization of findings for research purposes and consideration of patient care. Moreover, it was agreed that the participants have the right to withdraw from the study at any time without any negative consequences. In addition, the anonymity and confidentiality of participants were met in the study.

4. Results

The results of the analysis of the study data are presented in two sections:

Demographic characteristics and clinical characteristics in Table 1. One theme, 3 main groups, and 5 subgroups in Table 2. Explaining results along with the excerpt from the quotes from the participants in section 4.

The participants in the study were 17 women with breast cancer. The age range of them was 29 to 73 years with the average of 54 years. All of them were Muslims, Shiites.

The findings of this study revealed one core theme, which is supportive network and 3 main groups, which are family support including spousal and first-degree relatives’ support, community support including peer support group and governmental and non-governmental organization support, and healthcare providers’ support.

4.1. Family Support

The first major group identified during data analysis was family support. From the perspective of participants in this study, the family is the primary and the accessible source of support that promote hope in women with breast cancer.

4.1.1. Spousal Support

Married women in this study described their spouses’ support as warm, promising, and pivotal support. At the onset of diagnosis, they were worried about being rejected by their spouses due to fear of losing, particularly the loss of their breast resulted from their disease and side-effects of treatment ahead. However, as they recognized the support of their spouse, which was mostly emotional, sexual, and financial, they became more hopeful.

P14 (A 29-year-old woman): ‘Before the illness, I had problems with my husband. We intended to divorce last year. In spite of having these deficiencies (lack of hair, eyebrows, and breast) and problems in marital life. My husband did not leave me, unexpectedly, he supported me. We just fell in love.’

P7: ‘I often ask my husband about sexual satisfaction. She says indifferently: First, your health is more important to me. And secondly, I try not to look and he never looks.’

4.1.2. First-Degree Relatives’ Support

Moreover, the participants considered first-degree relatives’ support (parents, sisters, and children) that promotes their hopeful by accentuating that their relatives provided practical, emotional, and financial support over their course of disease and treatment.

P4 (Single participant): ‘My sisters and my mother helped me a lot. Maybe that's why I did not notice my illness like others. They did what they could. These things raise my hope.’

4.2. Community Support

The second major group specified over the analysis of data was community support including the support provided by peers and governmental and non-governmental organizations.

The participants asserted that community by providing welfare facilities and services could lead to the promotion of their hopeful.

4.2.1. Peer Support Group

In this regard, the participants expressed that peer support promoted their hope as a result of their participation in peer support groups on face-to-face, online, and Internet forms. Particularly face-to-face support was more appreciated due to taking advantage of its direct benefits such as sharing experiences, co-traveling, and participation in group discussions.

Participants indicated their excitement and enthusiasm while expressing the positive and constructive impacts of this kind of support, particularly on promoting their hopefulness.

P8: ‘I am alive in group and community. I should be with the group. I grow up with the group. I am hopeful in the group. We talk, laugh, dance, travel, and we are convenient together inside group.’

P17: I left all my friends, they behaved in a way as if I have a contagious disease or the law of karma flows to me. We are comfortable with each other (peers). We are not ashamed of the lack of breast, we are all the same’.

4.2.2. Governmental and Non-Governmental Organizations Support

Moreover, the participants explained that governmental (Insurance companies and social work etc.) and non-governmental (charities and volunteering etc.) organizations were effective in promoting their hope by providing welfare services, including financial and empowerment services. In addition, the participants enthusiastically referred to the empowerment services of these organizations presented as artistic, scientific, and sports courses.

P16: ‘We used health insurance services. The charity institution paid the rest. Many times the costs were scanty and even free. All of these are hopes. At least among stresses due to illness and treatment, thinking about the cost of the disease is reduced.’

4.3. Healthcare Provider’s Support

The third main group was related to the support offered by all members of healthcare providers including nurses, physicians, etc.

All participants highlighted that they have significant, positive, and valuable experience with the presence of healthcare providers during their treatment course. They all had a consensus that this presence along with informational support had promoted their hope.

P10: ‘My doctor is always available. He often has the physical, scientific, mental, and spiritual presence, even when I call or send a message to him. His presence is very transparent. He is full of presence. He speaks with hopefulness. As if, I’m not sick. It’s weird! I’m more hopeful in the hospital.’

5. Discussion

Analysis of the statements of the participants in this study, which was done with the aim of explaining the perception of Iranian women with breast cancer regarding the role of social support in promoting their hope, revealed that due to the nature of their disease, hopelessness can be considered as a nursing diagnosis for them. Moreover, they are in search of support resources, particularly a network of supportive resources, to promote their hopefulness.

The intended supportive network originates from the family and, then, extends to the community by receiving support from the communities that the patients are dealing with. Finally, the supportive network becomes unique with the support presented by healthcare providers.

The family can be regarded as a strong source of support that promotes hope for patients with consideration of the family-specific relationships among Iranian families. The family has a unique status in Iran’s traditional culture, and women are appreciated as the heart of the family by accepting their maternal and spousal roles. It can be claimed that being diagnosed with life-threatening diseases such as breast cancer can also be a serious threat to their family (5, 20). Hence, it can be concluded that disease does not only affect the patient, but the whole family is involved with the disease (8). Accordingly, the family does its best to support the patient. Moreover, the patients expect their family to support them to promote their hope. They consider their recovery as a goal, which must be shared with all members of the family to be achieved (20).

At the outset of diagnosis, the participants did not expect to receive their spouses’ support. The mentioned attitude stems from the old-fashioned beliefs in patriarchy and male superiority in Iran (21). Although it was expected that this perception would become more prominent in patients’ lives as a result of being diagnosed with cancer and appearance of the complications of treatment, receiving emotional support from the spouse, and decline of the mentioned traditional belief in Iran led to the promotion of hope in women with breast cancer in this study.

Support provided by families in general and spouses, in particular, are of great significance for maintenance, strength, and promotion of hope in women with breast cancer (11).

A number of studies conducted in this regard indicate that married women or those with a partner in their lifetime are more hopeful in comparison with single women (22). It must be noted that the supportive relationship between couples is reciprocal (13). Moreover, loss of breast as one of the symbols of femininity and sexuality may cause impaired body image, which can, in turn, lead to loss of hope and marital maladjustments (23, 24). On the other hand, hope in patients with breast cancer can be considered to be predictive of marital satisfaction (25); thus, women with breast cancer benefiting from their spouses’ support also indicate less disappointment and better marital adjustment (23, 24).

In line with the findings of a number of other studies (14, 15, 26) first-degree relatives of patients with cancer are accessible sources of support, who promote hope in all of the participants in this study.

First-degree relatives, as caregivers, build a bridge between the past, present, and future life of patients and do not allow the patients to be alone and hopeless during their treatment course (10). This type of support can be strengthened by taking advantage of the power of supporters, an increase of encouragement, and the establishment of close relationships between supporters and patients (4). Moreover, first-degree relatives’ support provides the hope that women with breast cancer need to overcome their disappointment (11).

However, in contrast with the promising support received from both family and friends in previous studies, (10, 13) the participants in this study cut all ties with their friends. Although the mentioned finding of this study has not been reported in other studies, some studies reveal that there was no relationship between the number of friends and presence of hope in patients with breast cancer (14).

To justify the findings related to patients’ escape from their friends in this study, cultural issues such as stigma can be highlighted. Stigma is a social labeling and culture-based phenomenon (27). In Iran, diagnosis of cancer is still considered as a taboo and negatively affects the hope of patients as it is mainly regarded in the form of karma and is synonymous with death. The majority of patients with cancer prefer to hide their illness from their neighbors, friends, and colleagues and that is why the patients escape from them. Hence, it can be concluded that from the participants’ perspective, escape from friends is, in fact, applied as a solution to escape the stigma.

Negative beliefs and cultural stereotypes in Iran have led to consideration of cancer as an ominous disease that not only result in an identity crisis, but also reduce social interactions of patients with cancer (28).

Thus, in this study, the patients described their peers as their best friends. They feel more comfortable to be with peers, perhaps due to their common pain. Accordingly, in line with findings of this study, exchanging experiences and having interaction with peers have been specified in a good number of studies as another way of promoting hope in women with breast cancer (12, 13, 26).

The prerequisite for receiving support from peers is face-to-face, phone, online, and Internet participation in peer support groups. Active participation in online peer support groups can promote hope in women with breast cancer as an opportunity will be provided for them to share their experiences, concerns, problems, and the identified effective solutions with each other. Moreover, they can interact with others, especially with breast cancer survivor peers (6, 29).

In a study conducted by Calumet (4), only one participant evidently referred to the support of these groups, which promoted her hopefulness. However, due to the significance of peer group support, her statements in this regard were provided as a theme in the study. Presentation of peer group support as a theme in the mentioned study was performed with the hope of inspiring researchers to conduct further studies in this regard and to take advantage of peer support groups to promote hope in patients with cancer.

In this study, governmental and non-governmental organizations were observed to be another support source to promote hope in women with breast cancer. Fortunately, many non-governmental organizations in Iran actively take part in specific fields, particularly breast cancer and, for instance, hold empowerment courses for patients. These non-governmental organizations are not able to conduct their activities without having legal permission and receiving financial support from governmental organizations.

As financial problems are relatively abundant in Iran, financial support provided by the government organization plays a significant role in the promotion of hope and health in patients, especially those with cancer.

Financial problems trigger loss of hope in women with breast cancer (20). A number of studies have revealed that hope was positively correlated with patients’ higher income (30).

The findings of this study revealed that healthcare providers’ support was another valuable source of support that promotes hope in women with breast cancer.

In Iran, at the time of receiving diagnosis news, hope is the patient’s crucial preference in doctor-breast cancer patient relationships. Apparently, strong communication skills of health professionals play an important role in promoting hope in patients with breast cancer. Hope-based communications are a fundamental aspect of caring for patients with cancer (31).

Advances in medical sciences have made the patients with breast cancer more hopeful. Furthermore, strong interactions and supportive services provided by physicians and healthcare providers are significant in promoting patients’ hope (32).

However, in contrast with the findings of this study, women with breast cancer in a study did not consider the support offered by healthcare providers to promote their hope as they did not expect this kind of support to be effective in promoting their hope (12).

5.1. Conclusions

As hope plays a critical role in the life, health, and survival of women with breast cancer, promoting hope has been specified as a strategy to promote health in patients with cancer. These patients emphasize the necessity of receiving support a supportive network to promote their hope. It seems, highlighting the supportive role of the family, especially the spouse, compared with the almost insignificant support of friends is a culture-based finding in this research that healthcare providers, especially nurses, can design and implement appropriate support-based care models to promote hope in patients with breast cancer by considering the social support resources specified in this study.

The main recommendation of this study is to conduct qualitative studies in different cultures with the aim of identifying other strategies to promote hope in patients with breast cancer. Moreover, further quantitative studies are appreciated in this regard to evaluate the level of hope following the interventions using the specified network of support in the present study.

5.2. Limitations of the Study

The specific limitation of this study is to disregard special stage of cancer and special type of treatment in the criteria for entry of participants to the study, while patients with special clinical stages and treatments may have different points of view. Another limitation of this study is the limitation in the generalizability of the findings of this study, as in other qualitative studies. Another limitation of this study, like other qualitative studies, is the limitation of generalizability.

Herth states that qualitative studies addressing hope present a number of strategies to strengthen patients’ hope and set the scene to conduct further intervention studies in clinical fields (33).