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Original article

Adjustment process in Iranian men to their wives’ breast cancer A. NASIRI, PHD, ASSISTANT PROFESSOR, Birjand Health Qualitative Research Center, Birjand University of Medical Sciences, Birjand, F. TALEGHANI, PHD, ASSOCIATE PROFESSOR, Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Isfahan, & A. IRAJPOUR, PHD, ASSISTANT PROFESSOR, Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran NASIRI A., TALEGHANI F. & IRAJPOUR A. (2015) European Journal of Cancer Care Adjustment process in Iranian men to their wives’ breast cancer Women’s breast cancer causes various problems in both spouses’ family life as well as enormous stress for their husbands. This grounded theory study aimed to define ways in which men adjust to their wives’ breast cancer and to present an appropriate model in this respect. Twenty-six individuals (22 husbands, 2 patients and 2 physicians) were selected through purposive and theoretical sampling. The data were collected through in-depth individual interviews. Strauss and Corbin’s method was used for data analysis. Data analysis revealed that Iranian men’s adjustment to their wives’ breast cancer occurs during the following three stages: the first stage turbulence after confrontation with the disease that contains categories ‘internal unrest’, ‘concerns about disease management’ and ‘sensing the beginning of disorganization in family life’; the second stage disorganisation of family life that contains ‘disturbance of family life’, ‘attempt to get rid of tension’ and ‘resistance against family life disorganisation’; and the third stage struggle to reorder family life consisting of ‘support to the wife’, ‘revision in communications with relatives’ and ‘seeking external support’ categories. Iranian men struggled for constant organisation of family life after their wives’ disease. Health providers should take measures to support the men by facilitating their adjustment to their wives’ disease.

Keywords: breast cancer, grounded theory, adjustment process, men, husbands.

INTRODUCTION Breast cancer is the most frequently diagnosed cancer among women in 140 out of 184 countries worldwide. It represents one in four of all cancers in women (International Agency for Research on Cancer (IARC) 2013) and is the most common cause of cancer death among women across the world (522 000 deaths in 2012) (International Agency for Research on Cancer (IARC) 2013). Correspondence address: Fariba Taleghani, Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Hezar jerib Str., PO Box 81746-73461, Isfahan, Iran (e-mail: [email protected]).

Accepted 5 January 2015 DOI: 10.1111/ecc.12293 European Journal of Cancer Care, 2015

© 2015 John Wiley & Sons Ltd

Breast cancer is speedily increasing in over 50-year-old women (Mousavi et al. 2009). The occurrence of the disease is particularly increasing in Central Asia. In Iran, breast cancer is the first malignancy among women (Harirchi et al. 2011) and involves, with the highest prevalence, 21.4% of all cancers in women (Noroozi et al. 2011). There, the prevalence of the disease is higher in 40–59-year-olds, compared with other age groups. Despite the advances in the equipment used for the diagnosis and treatment of breast cancer in this country, reports show an increase in the incidence of the disease (Montazeri et al. 2008). Fortunately, advances in screening and treating breast cancer have increased family life expectancy in breast cancer patients (Emilee et al. 2010). For instance, 74% of patients who had surgery at the proper time survived for 5

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years and 62% for 10 years afterwards (Deapen 2007). Thus, a lot of patients with breast cancer have survived and lived on in case timely diagnosis and treatment is conducted. During cancer treatment, women’s family roles and functions are imposed on their husbands, elder children and close relatives. Thus, cancer becomes a family problem and can affect the spouse’s adjustment to the disease (Ben-Zur 2001). This can be a more major problem in Iranian families since women play a central role in the family (Taleghani et al. 2008). While the stressful event of cancer involves all family members, one main social and family-related consequence of breast cancer is its effect on the spouse. The husbands bear a heavy strain in similar ways that their unwell wives do (Bar-Tal et al. 2005). Husbands of breast cancer patients experience their own specific tensions and have certain worries, which they do not often reveal to others (Bar-Tal et al. 2005). Results of a few studies hold that they have high anxiety and fear of future incidents, recurrence of cancer or death of their spouses; they feel defenseless in facing their wives’ cancer and cannot bear their wives’ suffering (Foy & Rose 2001). In addition to the problems that breast cancer causes for patients’ husbands, treatment – particularly surgical treatment – has a profound effect on their husbands. For example, Hoga et al. (2008) revealed that Chinese men whose wives had undergone mastectomy were not able to come to terms with their wives’ body defect, and they suffered ‘a kind of emotional maladjustment’. Since women with breast cancer are today cared and treated mostly in centres outside hospitals as outpatients usually through radiotherapy and chemotherapy, and because such patients prefer self-care and selfmanagement, care and support by their families are felt more needed (Harrow et al. 2008). On the contrary, one of the problems in taking care of such patients is the unpreparedness of family members, particularly the husband who plays a central role in the care given. Husbands bear deep stress and must control their anxiety if they want to be helpful to their wives (Julkunen et al. 2009). Various studies on the problems of women with breast cancer indicate that men are not indifferent to their wives’ disease; some of them have certain plans and strategies to decrease the effect of the disease on family life. However, it is not quite clear how these men understand their sick wives and interact with them in daily life (Harrow et al. 2008). There are few data about the relationship between these patients and their husbands and the way husbands support their wives (Julkunen et al. 2009). No such data are available as for Iranian women with breast cancer, 2

although Iranian women have a significant role in the family because of the deep emotional structure dominant in Iranian families and the responsibility they feel towards bringing up their children, towards their husbands, towards household affairs, etc. Because the husbands take the role of taking care of the women – usually with the least preparedness – their problems and concerns will not be solved if such problems, manners of adjustment and coping activities are not recognised. In addition, health providers (i.e. nurses, physicians, etc.) usually pay little attention to the patients’ family members, particularly to the husband and his role, during the improvement process of the disease; this is also a fact overlooked by the few studies conducted (Northouse et al. 1991; Hilton 1993; Pitceathly & Maguire 2003; Hoga et al. 2008). Thus, this is very significant to understand the process of men’s adjustment to their wives’ breast cancer. In this line, this study aimed to realise what kinds of worries the husbands of patients with breast cancer bear, what problems they face in their mutual family life and what reactions they have to the new conditions after their wives’ breast cancer. METHOD Sample The population included men whose wives had breast cancer and undergone modified radical mastectomy. The study took place in a governmental centre for breast cancer treatment of a university hospital in Isfahan. The initial participants who were recruited by purposeful sampling were men who came to the centre alongside their ill wives. The inclusion criteria consisted of men who lived with their wives, and their wives did not have any signs of the disease metastasis according to the available medical records. The participants also included men whose wives were at different stages of treatment (chemotherapy, radiotherapy or the check-up that followed the treatment). They were from different socio-economic levels. We used purposeful sampling at first and then we continued with theoretical sampling according to the codes and categories as they emerged. According to the codes and data collected, it was considered additionally necessary to include men who did not accompany their wives in the governmental centre or who visited private cancer treatment centres in order for us to enrich the data by taking into consideration the possibly different experiences they might have. Thus, two participants were from a private centre and three were men who did not accompany their wives and who were visited outside the centres. All of the © 2015 John Wiley & Sons Ltd

Adjustment in men to their wives’ breast cancer

men were justified about the purposes of the study, and those who gave informed consent participated in the study. Sampling continued until the data were saturated when the researchers found that similar codes were repeatedly cited by the participants. Thus, 22 husbands of women with breast cancer participated in the study. On the basis of the codes and data collected, moreover, some of the physicians who treated the wives or the wives themselves were interviewed as the theoretical sampling required. They could provide the researchers with complementary data in order to develop the theory. Therefore, there were two wives and two physicians in addition to the husbands.

Procedure This study was qualitative with a grounded theory approach. The data were collected through in-depth interviews by one of the researchers. The interviews began with general questions such as: ‘Please talk about what happened to your wife’, ‘What do you think about what has occurred?’, ‘How do you feel about your wife’s disease?’, and ‘Explain if any changes have occurred in your life due to your wife’s disease’. Then, the interviews continued dealing with more precise questions on the basis of the outcome of the initial parts of the interviews. The ethics committee of Isfahan University of Medical Sciences approved this study. For data analysis, the method of Strauss and Corbin was employed (Strauss & Corbin 1998). Data collection, analysis and interpretation were carried out simultaneously by the same researcher. The researcher transcribed each interview word by word. Any statement with a new abstract concept that could be labelled was considered significant. Thus, the researcher labelled the significant statements into initial codes line by line – a procedure called ‘open coding’. The transcripts were reread, and codes that were similar in meaning were grouped under the same categories. Then, in order to do axial coding, categories were related to their sub-categories and coding occurred around the axis of a category, linking the categories at the level of properties and dimensions. Later, selective coding, as the third stage of analysis, was carried out. The aim of selective coding is to integrate the categories along the dimensional level to form a theory that can validate the statements of relationship among concepts and fill in any categories in need of further refinement. In integration, categories are organised around a central explanatory concept (Strauss & Corbin 1998). Taking this into account, a commitment was made to a central idea in this study which was ‘effort to reorganise family life’, and © 2015 John Wiley & Sons Ltd

major categories were related to it through explanatory statements of relationship. Constant comparative analysis and theoretical sampling continued until each category was saturated and no new properties emerged (Strauss & Corbin 1998). Finally, the theory, which was grounded in data, was validated by comparing it to the raw data and presenting it to respondents for their reactions. Then, the theoretical scheme, a clear and graphic version of the theory that synthesises the major concepts and their connections, was outlined. Figure 1 is the integrative diagram, taken from our work. This diagram went through many revisions before we arrived at the final version. Both partners in the interviews were native speakers of the Persian language. The quotations were translated after analysis by a competent translator who was quite familiar with both languages, technical terms used by participants and principles of qualitative research. The translations were made to have an equivalent effect, i.e., to be contextually similar in Persian and English. It was tried to have fluent translations of the original quotations but without a loss of meaning. Quality criteria In order to increase the credibility of the study, the researcher tried to make the participants feel comfortable during the interview. This could psychologically ensure that participants would more honestly and collaboratively respond to the questions. In addition, the participants were chosen to have maximum variation in terms of age, job, habitation, education level and stage of the disease treatment of their wives (i.e. surgery, radiotherapy, chemotherapy or termination of treatment). To carry out member checking, the full transcript of the participant’s interview and its emerged codes were printed and presented to a few of them, and their ideas were asked. All of them confirmed the researcher’s interpretations from their statements. External checking was another way of approving the credibility of the study. The transcripts of the interviews together with the codes and emerged categories were given to three experts in qualitative research who were not taking part in the study to assess the data analysis and its correctness. Experts’ opinions about the codes were compared, and modifications were made on the codes based on ideas from the majority of the experts. FINDINGS The study indicates that men’s adjustment to their wives’ breast cancer is a process beginning from the diagnosis. 3

Turbulence aer confrontaon with the disease

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Internal unrest

Concerns about disease expenses

Sensing the beginning of disorganisaon in family life

‘concerns about disease expenses’ and ‘sensing the beginning of disorganisation in family life’. The second stage, disorganisation of family life, included the main categories ‘disturbance of family life’, ‘attempt to get rid of tension’ and ‘resistance against family life disorganisation’. Attempt to reorder family life, as the third stage, covered ‘support to the wife’, ‘revision in communications with relatives’ and ‘seeking external support’. In the whole process, the core variable was ‘effort to reorganise the chaotic family life’.

Aempt to reorder family life

Disorganisaon of family life

1 Turbulence after confrontation with the disease

Disturbance of the family life

1.1 Internal unrest Aempt to get rid of tension

Resistance against family life disorganisaon

Internal unrest began upon the wife’s cancer diagnosis, often in amazement and disbelief. To most of these men, cancer was an unexpected phenomenon that caused their astonishment and was associated with anxiety. One of the men said:

Support to the wife

I was much cluttered [. . .]. As a matter of fact, I am more involved in this problem. I didn’t believe that things would be like this. Perhaps, I could tolerate a more lenient disease but not this one. It was much unexpected. [P12]

Revision in communicaons with relaves

Seeking external support

Figure 1. Effort to reorganise family life (men’s adjustment process to their wives’ breast cancer).

Their adjustment followed three stages: ‘turbulence after confrontation with the disease’, ‘disorganisation of family life’ and ‘attempt to reorder family life’ (Fig. 1). The first stage, turbulence after confrontation with the disease, covered the main categories ‘internal unrest’, 4

This began from the time of initial confrontation of the husband with the wife’s breast cancer diagnosis and includes his experience, feelings, reactions and performance after confronting with the disease.

Furthermore, they were sometimes impatient in communication with others as a result of the stress load. They used to be warm and delighted in their communications. However, they were now impatient in their interactions; sometimes they turned quarrelsome and angry. One of the men said: Outside, I had become quarrelsome a bit. As soon as someone said something, I was not able to bear him/ her and I wanted to react to him/her immediately or I tried to express my feelings [. . .]. I took the opposing side against my boss right away, and if he insulted my colleague and the workmate was not able to respond, I became his defendant and could not control myself. [P4] Improper reactions and views of most people in community (who consider cancer a refractory disease synonymous with immediate death) worsened the internal unrest of the men and led to their sensitivity to others’ © 2015 John Wiley & Sons Ltd

Adjustment in men to their wives’ breast cancer

behaviours. After being informed about the disease diagnosis, close relatives and, sometimes, close acquaintances behaved differently, which triggered the husband’s unfavourable reactions. Most of these behaviours were weakening ones, which caused unrest and the men accounted them as destructive factors to the spirit of the wife and the family. One instance included ‘misplaced sympathy’ where people used phrases or words especially in a tone that hurts the feeling: When talking about the breast cancer diagnosis, some people either consciously and deliberately or simply indeliberately say: ‘Wow! You have cancer!’ or ‘Never mind!’ or ‘How do you wash yourself?’ [. . .] ‘Wow! You have lost your hair?!’ This is how they disturb your wife’s spirit. [P5] In some cases, the reaction of the men to the diagnosis was ‘fear’. They thought they would soon lose their wives, and ‘fear and horror’ of the wife’s death was the utmost internal turbulence and unrest for each and every one of them. Not only did the fear of the malignancy of the disease disturb the ease of the men, but also the possibility of the disease to be advanced increased the fear. The peak of internal unrest was the time when the fear was associated with the horror of the wife’s death. One of the participants explained: You know, cancer may be cured, but the term itself kills the patient. I mean, because it’s said a lot that one Mr. X or Ms. X had cancer and finally died, you are frightened at the probable death of the patient in the near future. [P22] 1.2 Concerns about disease expenses The majority of men, as the financial supporters of the family, took personal responsibility to pay for their wives’ treatment. Some of the husbands had economic problems because of the high costs of treatment. Furthermore, these men faced occupational problems because they had to spend their time at treating centre while their wives were being treated such that they could not be at their workplace properly; this decreased their income and triggered economic problems. A participant stated: I had to accompany my wife during chemotherapy sessions which impeded me from going to my workplace. This decreased my income and was very difficult. [P18] 1.3 Sensing the beginning of disorganisation in family life © 2015 John Wiley & Sons Ltd

Most of the husbands imagined the beginning of the disease as ‘a farewell to joys’ or ‘a reminder of future hardships’. They had annoying mental occupation and felt the imminent occurrence of disorder in family life. Among these mental occupations were ‘fear of treatment effects and bodily defects due to mastectomy’, ‘the possibility of failure of treatment’ and ‘the concern of disease recurrence’. One of the husbands said: We cannot do anything about it. Anyway, the disease has occurred. [. . .] When we find that the previous situation doesn’t exist anymore – however hard I, you, and others want to come up with the problem – it is only partly possible for us to accept the situation; our mind is entirely occupied. [. . .] When one has a benign tumor, it is very easy to cure it by means of medicine; but when the malignancy is mentioned, one is occupied with a negative mentality, mostly of future hardship. [P11] 2 Disorganisation of family life ‘Disturbance of the family life’, ‘attempt to get rid of tension’ and ‘resistance against family life disorganisation’ are the three sub-categories of the second stage of men’s adjustment process to their wives’ disease. 2.1 Disturbance of family life Upon the disorganisation of family life, men felt the ‘disturbance of family life’ because they realised the decreasing role of their wives in family management in that the wives were not able to organise family life affairs as before. Along with the progress of the disease and beginning of the treatment, the capacity of the patient to do household chores decreased. One participant said: One of her hands cannot operate properly [. . .], and household chores are mostly incompletely done. I am not capable of doing the chores well and have problems with cooking, washing, and so on. [P20] In addition to this, the stress and unhappiness imposed on the children resulted in a lot of suffering for the husband and added to the disturbance of the family. Thus, the father had to support both his ailing wife and the kids who suffered from their mother’s disease: On the days our child got to know that his mother was having chemotherapy, he was filled with stress so that he would wake up at midnight, had nausea, and even vomited. This was a serious problem [. . .]. He 5

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told his mother, ‘Are you going for the damn chemotherapy?!’ [P11] In fact, some of the children did not understand their mother. They reacted insolently because of the pressure they were experiencing. 2.2 Attempt to get rid of tension Although most men who participated in this study experienced unfavourable feelings and were challenging against internal unrest, they constantly tried to make the unfavourable condition bearable for their wives and for themselves. Not only they attempted to decrease tension for the wife in any possible way, but they also tried to reduce their own tension by getting more assurance of controllability of the disease. One of the things they did was to get information about the disease of the wife from different sources. Generally speaking, men were after decreasing their family’s anxiety burden and, to do this, they tried to make sure of the possibility of cure and survival of their wives by consulting physicians and specialists and speaking with patients with similar conditions. Resort to religious beliefs was another strategy to get rid of tension and organise the state of affairs. So the men tried to free from internal unrest by ‘seeking religious assistance’. This was why, in most cases, they accounted their wives’ disease as God’s will and test. One of them said: I myself always said this is only God’s will. I mean, I calmed myself by means of ‘ampoule of faith’; I mean, the influence of faith was very important to me. [P5] Many of them accounted faith in God as the factor of ease and acceptance of disease. One of them said: I think faith in God is one-hundred per cent important; I mean, it is the most important factor. It is certainly soothing and I really gained the fruit. When you have a pure relationship with God, I am certain that you receive the demanded result and obtain ease. [P4] Another thing these men did to relieve the tension of the disease diagnosis to the wife and, in fact, to organise the critical condition of family life was concealment. They did not express their feelings at the presence of relatives and even avoided expressing their feelings about the disease of their wives at the presence of the closest people. Because if they did, in their view, the relatives would ask the wife questions or give comments that would eventually upset the wife. Regarding this, one of the men said: 6

I didn’t express my feelings. When others asked something, I said very little. Even I was not such a person to reveal my feelings to my brother or sister. [P18] 2.3 Resistance against family life disorganisation Most of the men believed that they should resist family life problems and bear family life hardships. Upon the diagnosis, they turned to spiritual sources to relieve early psychological tensions; besides, interview with men who had passed this first stage and were in the family life disorganisation stage indicated that they accounted resisting against disorganisation a necessary feature for preserving family life. When a man is stuck in a situation like this, he should trust in God and seek help from Him, so God helps him and saves him from the suffering. [P19] Some men believed that faith was the power that could enable them to bear the problems arising from the disease of their wives: I believe that nothing is more helpful and conductive in tolerating trouble than the power of faith. [P5] Besides, they thought ‘mannish resistance’ a sign of their authority in bearing difficulties resulting from the disease of their wives. In fact, by resisting against family life disorganisation and managing it, they tried to organise family life. What I want to say is that a man who is under the unbearable distress associated with their wife’s dangerous cancer must resist; a man who cannot resist is no man. [P13] 3 Attempt to reorder family life During this third stage of men’s adjustment process to the wives’ cancer, which covered three main categories, including ‘attempt to improve family relationships’, ‘revision in communication with relatives’ and ‘seeking external support’, men tried to take measures to reorder their family lives. 3.1 Support to the wife Most of the husbands tried to improve the physical and psychological conditions of their wives and organise the state of family affairs. They tried to show their love and affection to their wives, even more than before, in order to help them raise their decreased morale, and express more © 2015 John Wiley & Sons Ltd

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hope through the close communication with them, so that the new situation would be bearable, and family tensions would decrease. One of the manifestations of emotional support to the wife was respect for and gratitude to her. Men tried to improve their wives’ morale through respecting them at the presence of others and showing selfcontrol when angry. One of them said: You should support your wife; you should tell her that nothing strange has happened. However, this is what has occurred [. . .]. You should remember to respect her at the presence of others; you should also show self-control during conflicts; you should not tell yourself that under the present situation, I must seek excuses. [P11] In addition, by adopting any possible way and all their abilities, men tried to take measures to keep their wives away from mental preoccupation. Hiking, going on picnics and taking trips were among supports a husband gave to his wife to improve her morale and emotions. Another obvious kind of men’s emotional support to their wives was their association and sympathy in all stages of the disease and treatment. One of the men said: I try to manage the affairs so that I do not transfer my sadness to her. [. . .] I help her and try to be with her all the time. I do not retract. Even if I am at work, I appoint someone to accompany her, or if I don’t go to work, I stay home and go nowhere. [P12] As mentioned in item 2.1, in the second stage of men’s adjustment to their wives’ disease – disorganisation of family life – men felt the decreasing role of their wives in family management as the wives were not able to organise family life affairs like before. This was usually caused by their inability to use the hand of the operated side of the chest. However, during the third stage – attempt to reorder family life – the husbands were aware of the fact that in case of pressure on her hand, the hand would become inflamed and sore. Therefore, they tried to prepare the situation for their spouses’ relaxation and manage household affairs themselves. 3.2 Revision in communication with relatives According to the husbands, each of the relatives of the wife treated her and her family differently. Some of them sympathised with her with pitiful expressions or depicted morale weakening behaviour out of their fear or ignorance. On the contrary, some had supportive and assisting behaviour towards the wife. Thus, the husbands tried to stop or decrease their communication with the ones who © 2015 John Wiley & Sons Ltd

weakened the wife’s morale but strengthened their ties with the supporters. 3.3 Seeking external support One of the principle categories inferred from the analysis of the participants’ comments was their awareness of requiring others’ support and their usual attempt to seek the available supporting sources as much as they could in order to reorder the chaotic situation of family life. Seeking economic supporting sources, expecting the employer’s support, asking close relatives to assist and demanding support on the part of health providers were instances of men’s support-seeking. Since economic problems of men were among the most important worries against managing their wives’ disease, they were usually seeking for financial support. One of these sources is the financial support from health insurance companies. Although health insurance most often does not cover all drugs and expensive requirements of the patients, men often think of health insurance and a few governmental organisations as additional financial sources. They are satisfied with the support of these organisations. In addition to these, the husbands felt the need for emotional support on the part of their close relatives. They were not able to have a comfortable life without aid from close relatives (e.g. mother or sister or others). In overcoming the problems and reordering family life, the role of health providers, particularly the physician, is undeniable in supporting the husband and his wife. A man said: When I took the lab results to the physician, he consoled me and renewed my hope. [. . .] One of the nurses was a friend of my wife; she talked to her, and my wife felt relaxed as a result. The physician himself entered the room and talked to her for half an hour. His talk was comforting, and my wife accepted his words. [P15] Effort to reorganise family life In all, the analysis of the data indicated that the men were not passive against life disorganisations, reacting and behaving with an overall objective from the first moment and throughout all the stages of their wives’ breast cancer. The constant comparative analysis of the data revealed that all these behaviours were related to the core variable named ‘effort to reorganise family life’. This was, in fact, the most comprehensive subject that could describe men’s adjustment process to their wives’ breast cancer. 7

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Thus, now we know that men’s adjustment to their wives’ breast cancer occurred during a three-stage process beginning from the diagnosis of the disease. The first stage was a sign of ‘internal unrest’ beginning in men upon hearing their wives’ breast cancer. They tried to keep family life organisation and not let the state of affairs divert from their routine. The second stage was ‘disorganisation of family life’, which usually starts with treatment and develops along with progress in treatment measures. However, the men gradually came to know that it was not possible to live the same as before and that it was necessary to revise many aspects of family life. They assumed themselves in charge of their wife and family, always trying to reorganise the chaotic conditions of life. During the third stage, which usually starts towards the end of treatment and continues until the treatment finishes and even after that, the husbands made constant attempts to reorder family life, which resulted in changes in their life and interactions with their wives and relatives. The more time passed from cancer diagnosis, the better men could perceive the new conditions and take hold of the situation, struggling to reorganise their family life (Fig. 1).

DISCUSSION According to the first stage of the ‘effort to reorganise family life’ model, men experience various psychological reactions after confronting with their wives’ breast cancer. In fact, they experience ‘internal unrest’. They consider their wives’ disease as a stressful situation causing internal turbulence and discomfort, which results in reactions such as worry and concern, amazement and astonishment, fear and sensitivity to others’ behaviours. Various other studies have reported men’s worry and anxiety following the diagnosis of breast cancer in their wives (Harrow et al. 2008; Morgan 2009; Naaman et al. 2009). Morgan’s (2009) study demonstrated that husband’s tension and anxiety are associated with wife’s sadness and distress. Most of the men who participated in the present study thought they would soon lose their wives, and this added to their internal turbulence. Different studies have indicated that cancer diagnosis, irrespective of its type and location, can frighten the spouse (Maliski et al. 2002; Brodeur 2005). Similar studies have confirmed husbands’ feeling of fear and threat at the diagnosis of their wives’ breast cancer (Northouse et al. 1991; Feldman 2001). Northouse et al. (1991) and Feldman (2001) maintained that men’s fear and horror mainly arise from the nature of breast cancer and its dangerous treatments (Northouse et al. 1991; Feldman 2001). 8

Another reaction of the husbands following their wives’ breast cancer was amazement and astonishment, which strengthened the first stage of our model. Brodeur (2005) believed that when cancer develops, other family members are shocked because of the unpredictability of the disease, and they considered the disease as unjust. The first stage of the model that emerged in this study also indicates that a concern of men is disease expenses, which has a significant share in disorganisation of husbands’ lives. Economic concerns are among factors that men consider as adding to their problems. Kadmon et al. (2008) referred to economic problems as the main concern of men in adjusting to their wives’ breast cancer, saying that many participants in his study were unable to pay for the treatment expense of their wives. The emerged model states that husbands of breast cancer patients sense the beginning of disorganisation in family life. Sensing ‘a farewell to joys’, ‘remembering future problems’ and ‘thinking of losing their wife’ are instances of such preoccupations. Harrow et al. (2008), too, mentioned constant mental obsession with the consequences of the wife’s disease on the part of the husbands as a finding of their study. On the basis of their study, ambiguity and uncertainty reveal a kind of undecidedness in men confronting with their wives’ breast cancer. They believe that husbands are constantly involved in future plans and try to take specific approaches to meet their own needs. Husbands feel they are living in an afterworld and are always prone to changes, which would fade their hopes. Their anxiety regarding the probable loss of their wives triggers this feeling (Harrow et al. 2008). It was found in the present study that disorganisation of family life increases along with the progress of the disease, the beginning of treatment and the problems that follow. In this regard, Northouse et al. (1991) believed that husbands of patients under radiotherapy and chemotherapy bear more hardship in their adjustment to their wives’ disease. According to Budin et al. (2008), husbands have a lot of stress due to family life problems since they are very close to their wives. On the basis of our study, one of the manifestations of disorganisation of family life was disturbance in the family life. Brodeur (2005) introduced the effects of chronic diseases on family life as one of the main categories and wrote that such a disease is an influential phenomenon in family life, which brings about daily imposed needs for them. As for this, Pitceathly and Maguire (2003) emphatically called the changes in everyday family life of husbands as the main finding. The men tried to make sure of the survival of their wives through gaining information about the disease and about the recovery of similar patients. Asking the physician and © 2015 John Wiley & Sons Ltd

Adjustment in men to their wives’ breast cancer

health providers, and getting acquainted with similar cases were ways of obtaining information. According to Foy and Rose’s (2001) study, husbands of patients with breast cancer feel a sense of deprivation of, and suffer from, shortage of information about the disease. However, Hoga et al. (2008) maintained that husbands were satisfied with the advice provided by physicians and nurses regarding emotional reactions, future care requirements and the complications of chemotherapy. To the husbands, this was an important factor in their adjustment to their wives’ disease (Hoga et al. 2008). On the basis of our model, the other positive strategy that Iranian men work out to relieve from stress is to seek religious beliefs. In fact, religious beliefs and resort to famous men of religion play a considerably important role in the religious culture of the Iranian men and can help them in the face of their wives’ cancer. In this regard, the men in the present study considered their wives’ disease as God’s will and test. Belief and trust in God and resort to spirituality were factors helpful to their acceptance and adjustment to the disease. Hoga et al.’s (2008) study also revealed the importance of religious beliefs. Husbands of breast cancer patients took refuge in religious sources when confronted with the disease of their wives. They accounted these sources decisive in relieving problems (Hoga et al. 2008). According to the second stage of the present model, men usually endeavour to organise family life in the face of all problems related to their wives’ disease since they consider themselves responsible to their families, particularly to their wives. Thus, they try to resist against difficulties and bear problems in any possible way through reliance on spiritual sources and mannish resistance. In Brodeur’s (2005) study, it was shown that family members tried to find effective ways to change family life in order to bear problems better. Support to the wife is one of the measures that men take to reorder family life. During this third stage of our model, men try to provide support to their wives in any possible way in as much as their abilities and facilities allow. Naaman et al. (2009) believed that the husband’s support of the wife can have a facilitating effect on bearing physical and psychological problems by the patient. Besides, Bultz et al. (2000) accounts the husband’s support and sympathy as important and fundamental factors that can lead to decreased emotional problems (of the wife) after mastectomy. Establishing a more sincere relationship with the wife, consoling and sympathising were among the measures taken by husbands to improve the psychological condition of the wife. They tried to increase their wives’ morale through expressing love and affection to © 2015 John Wiley & Sons Ltd

them more than before the disease. Naaman et al. (2009) believed that emotional support of the sick wife by the husband decreases her stress and depression symptoms and improves her adjustment to her roles after recovery. They wrote that ‘emotional support’ includes items such as communication of care, common concern, empathy, comfort and reassurance of the patient which become apparent verbally or non-verbally (Naaman et al. 2009). Carter and Carter (1994) introduced a dyad model of husbands’ reaction that appeared either in the form of withdrawal from the patient or overprotection of her. In the first reaction, the husband tries to continue his routine profession and is apparently not affected much by cancer diagnosis and its malignancy. In the second reaction, he tries to be positively effective and give appropriate replies to questions regarding his wife’s disease. Moreover, he pays attention to her fears and concerns about the disease (Carter & Carter 1994). Our study revealed that most of the husbands had accepted the inability of their wives to do domestic affairs and had taken their role in order to show their company, empathy and love. Northouse et al. (1991) considered management of changes in everyday family life as a main concern of husbands when trying to reach adjustment. In addition, Hoga et al.’s (2008) study indicates that men accounted themselves responsible to do household affairs, previously done by their wives, prior to mastectomy. They played the main role in doing household affairs during all stages of their wives’ cancer (Hoga et al. 2008). It is necessary to note that men’s duty in the Iranian and Islamic culture is mainly to provide for the expenses of family life while women take care of the domestic affairs and children almost completely. Upon women’s involvement with cancer, men have to play a dual role, where they manage both internal and external affairs of the house despite the fact that this is contrary to the dominant culture of the Iranian society. According to the third stage of the ‘effort to reorganise family life’ model, husbands attempt to revise their communication with relatives so that it would lead to psychological comfort of both spouses. This is done to reorder the chaotic condition of family life. To reach this goal, they would either minimise their communication with relatives whose behavior can weaken their morale or they would break their ties with them. Besides, they prevent their wives’ communication with such people. It is interesting to know that in the Iranian society, diagnosis of cancer can be equal to death. Therefore, people with cancer prefer not to become infamous in the society as cancer patients, which, in turn, can impose a heavy psychological and emotional burden on the patient 9

NASIRI ET AL.

and his/her family. What the patients prefer to do is to hide their sickness from other people in order to avoid their pity. Hilton (1993) wrote that a few of the husbands were satisfied with their familial relationship, but others were not. They complained of the decrease in their communication (Hilton 1993). According to Kadmon et al. (2008), men’s decreased communication ranged from moderate to severe, even as much as to feel lonely. Seeking external support to reorder the chaotic condition of family life was another experience of the interviewed men forming one of the main themes of the third stage in our model. In Hoga et al.’s (2008) idea, family members, neighbours and friends can act as suitable supporting sources for the patient and her husband during the disease treatment. Adjustment to breast cancer in family members corresponds directly with their access to supporting sources, while lack of them causes more emotional distress. It can even cause disorder in their moods and emotions (Pitceathly & Maguire 2003). Similarly, husbands in the present study usually felt the necessity for others’ support and attempted to use existing supporting sources to reorder the chaotic condition of family life. To support husbands of patients with breast cancer is an important issue that is usually overlooked by entities that can act as supportive sources. Various studies have emphasised the necessity of financial and occupational support of the husbands (cf. Northouse et al. 1991; Hilton 1993; Feldman 2001; Foy & Rose 2001; Brodeur 2005; Kadmon et al. 2008). In fact, increasing husbands’ quality of family life and the supports they receive corresponds to a decrease in their psychological tension (Wagner et al. 2006). In this study, husbands seemed to have limited supporting sources. They tried to find support from any possible source, although they sought support from health providers more than any other source. Northouse et al. (1991) wrote that although husbands bear even more stress than the patients themselves, they are less likely to be supported by health providers than other family members; many of the men held that they rarely communicated with physicians and nurses and had a little chance to seek their assistance. In addition, the health providers were busy because of the high number of patients they had (Northouse et al. 1995). Omne-Pontén et al. (1993), too, believed that husbands of the patients are overlooked by health providers. However, as Hoga et al.’s (2008) study indicates, the husbands were satisfied with some supportive aspects of health providers, particularly, appropriate treatment measures, perfectness of care, certainty of due care, managerial organisation and available technological facilities for treatment. Pistrang and Barker’s (1998) study 10

showed that husband’s knowledge about breast cancer is decisive in the degree of his assistance to his wife. Different studies have recommended that health providers and specialists must guide the spouses during all the stages of diagnosis, treatment and recovery in order to prepare them for better adjustment to the new condition (Bultz et al. 2000; Maliski et al. 2002).

STUDY LIMITATIONS We were forced to limit our study to Isfahan city mainly because it was not possible for us to provide samples from other regions in Iran. Therefore, although we tried to study in depth the problems that Iranian husbands of breast cancer women experience and tackle with, we cannot generalise the concrete findings to different contexts. However, other husbands who are faced with their wives’ breast cancer diagnosis might benefit from the current findings. In addition, the emerged model can be culture proper, making the applications of the model limited in other contexts.

CONCLUSION This study revealed that the interviewed husbands bear a lot of family life problems after confrontation with the disease. Confrontation with their wives’ disease was followed by internal unrest, and in general, unfavourable psychological reactions. Husbands’ most important concern about their adjustment to their wives’ condition was family life disorganisation. They tried to resist the problems and prevent disorganisation from affecting their family life by attempting to improve family relationship, giving emotional support to the wife, revision in communication with relatives, seeking financial support from different sources, etc., hence, the necessity of supporting the husbands and helping them towards effective adjustment to problems. Nurses can accelerate and simplify a husband’s adjustment through appropriate initial and later comprehensive assessment of his psychological state and his reactions to his wife’s disease. Consultation provided by psychologists, psychiatrists or psychology nurses to husbands – and other family members – can improve their knowledge and capability to adjust to the wives’ breast cancer. It can, moreover, encourage other family members to help the men. Nurses as well as other health providers can take measures to support men’s effort to facilitate their adjustment to their wives’ disease and to help them reorganise their family life. © 2015 John Wiley & Sons Ltd

Adjustment in men to their wives’ breast cancer

ACKNOWLEDGEMENTS The authors would like to appreciate all participants in this study for their kind cooperation. Special thanks go to Isfahan University of Medical Sciences for its funding and Birjand Health Qualitative

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