The present qualitative study was performed to explore the coping strategies of Iranian women with BC. According to the results of this study, Iranian women resort to psychological and behavioral strategies to adapt to the disease and its treatments. Behavioral strategies are inclusive of change nutritional habits, improving lifestyle by eliminating or modifying factors that are perceived to trigger BC, trying to stay active and continuing past routine activities, getting help from government or private support systems for physical and mental needs and efforts to increase their knowledge and literacy about the disease process and its treatments after diagnosis and chemotherapy to combat the disease. In the psychological strategies, participants mentioned resorting to denying and not believing in the diagnosis of BC, using various methods of psychological empowerment, spirituality and seeking help from religion and religious beliefs, and finally relying on the help of family and relatives.
Behavioral Coping Strategies:
Many participants in the present study stated that they tend to modify their lifestyle and diet to correct the unhealthy lifestyles in the past or to prevent recurrence of the disease. Qualitative studies of BC survivors in other countries have reported changes in nutritional habits and styles in order to maintain health and reduce fatigue caused by the BC. In most studies, using a low-fat diet and consuming more fruits and vegetables and avoiding high consumption of red meat have been mentioned as beneficial changes in diet. The results of these studies are consistent with the results of the present study (38–40).
As mentioned above, another way to deal with BC was to change the lifestyle and correct unhealthy lifestyle habits. In this regard, various ways such as increasing physical activity such as work at home, walking, going to gyms and hiking were mentioned. Similar results have been reported in other qualitative studies (41). In a qualitative study on Chinese-Australian BC survivors, participants reported that to exercise kept negative thoughts away from them. Also, the participants reported doing Tai chi (thought to be very useful in combatting depression), walking, and using weight machines at the gym for coping with their disease (38).
In a qualitative study of British cancer survivors, most participants were aware that physical activity is good for general health and some of them stated the benefits of physical activity definitely relating to cancer and other chronic conditions, such as cardiovascular disease (42).
Also, most of the participants of a qualitative study on cancer survivors in Taiwan, supposed that cancer reflected their past unhealthy lifestyles. To avoid problems, they attempted to adjust their lifestyle, change their unhealthy diet habits, increase physical activity, abstain from tobacco and alcohol, and manage their emotions (43).
Another coping style with BC in the present study was to try to return to routine activities and lifestyle. Participants stated that they try to do all the housework themselves, such as cooking, making pickles and jams, shopping, and even going to a sewing class, walking, participating in public activities, and attending at their work place and doing their job responsibilities. In fact, by doing these activities, a sense of control over the current situation is created for them.
In other qualitative studies, BC survivors were willing to return to normal activities. They believed that activities related to home, job duties, self-care, child care and participation in social activities lead to better adaptation to the disease and treatment complications. Also, the person feels life satisfaction, increases the quality of life and even improves her body image (44–46). An important finding in Yamani Ardakani (2019) on Body image and its relationship with coping strategies in BC survivors, was that employed and educated women with BC had better body image compared to the others (47). Also, Cancer survivors in Taiwan to improvement in physical and emotional wellbeing, stated that participating in social activities resulted in greater satisfaction with life (43).
Another strategy used in the present study to cope with BC was to use of specialized and cancer support services. Access to such services reassures the cancer survivors and reduces concerns about the disease and its treatments. However, in most cases, these services only cover patients' physical problems, and counseling on patients' psychological issues remains unspoken and unresolved. In confirmation of the results of the present study, other qualitative studies also expressed the need for physical care and psychological counseling centers for cancer patients and people who have undergone hysterectomy (48–50). However, for some patients or survivors, geographical access to such services is limited (46). Positive support, especially from family, friends, and healthcare professionals, helped women with BC deal with the uncertainty they felt after the diagnosis (44). In a mixed method study about coping strategies during BC in Latina women, the participants expressed the need for an online community with doctors and program references in their areas and the ability to interact with other women who are going through a similar process or who have already gone through it (51).
Another way to cope with BC was to search for more information about the disease, its course, complications, treatments, medical and counseling services. However, one of the participants preferred not to learn much about the disease and its course. Because she thought that getting more information would increase stress and make her feel out of control. But, other studies have shown that being aware of one's current condition increases cognitive and behavioral adaptation and lead to resistance against stress, redirect inappropriate coping activities, facilitate the problem-solving process, and result in the ability to tolerate increased levels of stress(46, 52). According to a qualitative study on Latina women, online resources may be a useful way to disseminate knowledge and awareness and to provide a unique support system (51). The results of the present study and smith et al (2017) study on British cancer survivors, showed that little information was given from oncology health professionals on how to achieve adequate levels of physical activity and many participants sought information via other methods, such as, media and websites (42). Also, Khakbazan et al (2014) reported difficulty in accessing health care services for a number of reasons such as distance and lack of knowledge of breast clinic locations and structural factors related to the health services such as the long process of admission, and challenges with referral systems were identified as factors that delayed timely medical help (53).
Emotional coping strategies
Many of the participants stated that in the early stages of diagnosis, they could not believe that BC had happened for them. In other studies, the experience of the denial phase in the early stages of diagnosis has been reported (41, 53, 54). A study on quality of life in Iranian BC survivors, reported that when participants are faced with BC diagnosis, they will experience a variety of emotions such as fear, shock, disbelief, sadness, hostility, anger, depression, anxiety and other feelings of psychosocial distress (55).
In the present study, different methods of psychological empowerment were used to cope with BC. For example, wearing nice clothes, using wigs and special bras, not wanting to interact with negative people, positive thinking and focusing on the positive aspects of personal life. Some participants even encouraged their disappointed families. Our findings have been supported with other qualitative studies (23, 46, 56–58). For example, Yamani Ardakani (2019) and Hajian (2016) in qualitative studies on BC survivors, stated that the most important strategies for coping with BC were problem-focused coping strategies, acceptance and positive and constructive thoughts(44, 47) .
In this study, the patients believed in their disease as a spiritual fate, a test conferred on them by God. They believed that the disease and its cure was in the hands of God and by the will of God, and in this way they found peace. There has been a positive role of prayer and trust in God in the present study and other qualitative studies that have been done in different parts of Iran on women with BC (20, 23, 55, 57, 58). In a qualitative study using the phenomenological approach to describe the ways Iranian women coped with BC-related complications and changes in their lives, most of the participants believed that they get cancer because it was God’s will; in some cases, the patients believed that “the disease came from God; we cannot prevent it, and it does not matter what we do.”(58). In fact, the use of prayer and reliance on a transcendental power has been reported in qualitative studies in other countries with different religions (24, 38, 59–61).
Another method of coping with BC in the present study was to rely on the help and emotions of family, relatives, and friends. The most common people who helped participants to adapt during diagnoses and treatments and complications of illness and treatment were family members, especially spouse, mother, neighbors, and friends. Most of the participants stated that they had noticed the depth of empathy and loyalty of their spouse after BC diagnosis, and some mentioned that their spouse had changed his behavior and he became kind and good-natured unlike the past. This has been confirmed in other qualitative studies in Iran on women who have had a hysterectomy or BC. Especially the role of the spouse in adapting women to diseases is very critical and important and improves mental health and quality of life (20, 23, 55, 57, 58, 62, 63). A meta-ethnographic synthesis on help seeking behaviors of women with BC, revealed that family and other relatives tried to provide emotional and financial support for women, as well as to reassure, encourage, and advise women to seek treatment. In some cases, the pressure bought to bear from others (spouse, relatives and colleagues) resulted in medical seeking (53). Studies in other countries have also reported the key role of the spouse in adapting to BC. A study about spousal support strategies for patients with BC in China showed that there was a role change for the husbands, from spouse to protector and caregiver, upon diagnosis and during treatment, and a return to the role of spouse following the completion of treatment (51, 64).
A challenge for women coping with BC was the feeling of sympathy, compassion and some inappropriate behavior of friends, relatives and wider society. Participants viewed compassionate behaviors towards them, accompanied by exaggerated affection from relatives or friends as a barrier to their coping with the disease and as creating a distressed feeling. They did not believe they deserved such sympathy and compassion but ordinary behavior without exaggeration. They believed inappropriate behavior would collapse their peace and worsen their condition. Behavior towards people who identified them as a person with a dangerous disease resulted in their social isolation. Some participants did not describe the role of some relatives, such as their sister or daughter-in-law, as supportive and friendly. They were forced to stay away from them because of their negative thoughts and negative words. Similar results have been reported in other studies (24). Fasihi Harandi et al (2010) reported that most of their participants kept the illness as a private issue because they did not like negative and pitying reactions from family, friends, colleagues and society (55).
In this study we found that participation in homogeneous groups were another way that affected the participants' coping response. The existence of support groups caused the woman to discuss her problems and experiences openly and created a supportive atmosphere within which to exchange knowledge and awareness concerning the resources and facilities. This sort of interaction and mutual communication as well as formation of support groups and exchanging successful experiences was shown to be helpful for the patients. A systematic review on Peer support interventions for BC highlights peer support interventions for improving quality of life and reducing distress among BC patients (65). Peer support helps the patients by providing hope and a way to cope, replaces other social roles that are weakened by disease, and offers understanding through shared experiences (21, 46, 66). As there is no organized group for BC survivors in Iran, the necessity to establish such groups seems essential.
One of the strengths of the present study is to explore the emotional and behavioral coping strategies with BC in survivors. While in other studies that have been done so far, most of them have focused only on the aspect of psychological coping styles. Second, the present study was conducted in Mashhad, where patients are usually referred from other cities and it was possible to select participants with maximum cultural diversity and different socio-economic level. The limitation of the present study was that it was conducted in the Iranian-Islamic community and can only be generalized to similar cultures.