The perceived social support by Iranian women with breast cancer: a qualitative study

Social support has an important role in improving health outcomes and is considered as one of the crucial aspects of the modern care in cancer patients. Therefore, this article aims to explain the perceived experiences of women suffering from breast cancer towards social support. In this qualitative study, 22 women with breast cancer were selected through purposive sampling from 5 hospitals affiliated to Urmia University of Medical Sciences. The data were collected through semi-structured interviews and were analyzed by the Conventional Qualitative Content Analysis and Graneheim’s and Lundman’s approach, using MAXQDA software, version 10. After completion of the analyzing process, 6 categories were appeared including “creating an empathic atmosphere by family and community,” “being in relationship with others,” “adaption to disease,” “giving meaning to life,” “satisfaction with the role of healthcare providers,” and “the impact of others support in fighting with the disease.” According to the findings, good social support during the illness can result in the spiritual, mental, and physical well-being of the patients and is one of the most effective factors in fighting the disease and feeling of recovery. The findings of this study can be used to develop plans to help the patients to achieve more support from the family, healthcare providers, and the community and even providing the required supportive care for this group of women.


Introduction
The rapid increase in breast cancer rates in recent decades and its deleterious impacts has drawn the attention of the specialist as well as the people to this disease [1]. Every year more than 6 million women around the world are diagnosed with cancer [2] and in Iran, more than eight thousand new cases are diagnosed with cancer every year [3]. The mean age of women with breast cancer in Iran is 10 years lower than that in high-income countries [4]. Women with this disease suffer from a variety of social, psychological, mental, and physical problems during the process of diagnosis and treatment of the disease [4,5]. Controlling cancers, reducing the death rates, early diagnosis, and improving the quality of life of the patients with cancer are among the long-term goals of the National Cancer Control Program in Iran [6]. One of the most important factors that impacts on improving the quality of life of these patients is social support [7].
Social support has a vital role in the quality of life and other outcomes after diagnosis and treatment of breast cancer [8,9]. Social support exists in the form of both physical and psychological assistance from family, friends, and others during difficult times [10]. Various studies among the survivors of breast cancer revealed that improper social support could result in an increase in the death rate [1], anxiety and depression after diagnosis [11], and rendering the proper amount of social support can lead to good social, psychological, and physical performance, and improvement of the quality of life [12], less distress [13], emotional wellbeing [14], decreasing the risk of illness [15], and long-term survival [7]. The family as a source of social support has a significant impact on the patients' coping strategies and their ability to cope with this disease [1]. Furthermore, when these women are placed in a social group, they tend to live longer, and their emotional health is enhanced as well [12]. Getting support from others acts as a shield against the negative side effects of this disease and has a strong relationship with the psychological performance of the patients. Patients with rich sources of support tend to have better psychological and physical status than women with poor sources of support [11]. Therefore, social support is considered as one of the crucial aspects of the modern care in treating cancer [12].
Perceived social support plays a vital role in adapting to severe diseases such as cancer [16]. Thus, discovering and describing the perceived social support in women with breast cancer is of considerable importance. Furthermore, understanding women's experience of social support can assist the caregivers to provide the required measures to support these patients. However, studies that deal with social support in women with breast cancer are rare so far.

Aims of the current study
The current study, with a qualitative content analysis perspective, was conducted to explain the perceived experiences of Iranian women suffering from breast cancer towards social support during their illnesses.

Methods
The conventional qualitative content analysis was used to explain the perception of Iranian women with breast cancer toward social support. Qualitative content analysis focuses on subject and context and offers opportunities to analyze manifest and descriptive content as well as latent and interpretative content. According to the ontological assumptions of qualitative content analysis, researchers strive to reveal meanings in the data using various degrees of interpretation. Based on epistemological assumptions of qualitative content analysis, data and interpretation are co-creations of the interviewee and the interviewer, and interpretation during the analysis phase is a co-creation of the researchers and the text [17].
Social support is a multidimensional concept and in these women, it is affected by various factors such as demographic characteristics, family economic status and socio-cultural context, and other variables. So, according to the purpose of the study, which is to explain the concept of social support based on lived experiences of women with breast cancer, content analysis was used.

Setting
The study was conducted in five teaching hospitals and oncology centers affiliated to Urmia University of Medical Sciences and interviews were carried out at these settings. Patients after diagnosis of breast cancer are referred to these centers for surgery, chemotherapy, and radiotherapy.

Recruitment of study participants
The research population included women suffering from breast cancer. Initially, participants were selected through convenience sampling method. Then, after analyzing the initial interviews, we implemented purposeful sampling to recruit our study participants. Recruitment of heterogeneous participants provided us a wide range of social support experiences among women with breast cancer. We continued to recruit participants to interviews until saturation and verification of data have achieved. Inclusion requirements included as follows: aged 18-80, the capability to speaking and responding in Persian or Azerbaijani, and being diagnosed at least 6 months ago. Exclusion criteria included as follows: participant's death, disease aggravation, and being unaware of their disease.

Data collection
Data collection took place during spring and winter 2019. Interviews were conducted to find out and explain the perceived social support based on the lived experience of women with breast cancer. The women meeting the eligibility criteria were selected based on purposive sampling. After we obtained the willingness to participate, an appropriate place and time for an interview were arranged. Data were collected via face-to-face interviews individually by the first author (26 interviews with 22 participants) in a private room. The maximum diversity of participants was selected for the study concerning their age, academic background, employment status, marital status, number of children, economic status, and ethnicity. Sampling was continued to reach the data saturation and finally, with the sample size of 22 participants, the data were completed.
Saturation is the repetition of information obtained and the confirmation of previously collected data, so that no new information is obtained [18]. If the saturation of data is incomplete, it may cause problems in data analysis and prevent items being linked together [19]. In this study, the number of samples was not determined in advance. Sampling continued until no new code emerged from interviews and the categories were saturated in terms of criterions and the research question was answered. After 19 interviews, we were finding repeated rather than new themes. In order to make certain that no data is disclosed; three more participants were interviewed.
The data were collected through semi-structured interviews, using an interview guide. The interview guide consisted of open-ended questions. For instance, one of the questions asked from the participants was: Would you please tell me about your experience on social support you received during the disease? For each section of the interview, the probing questions were asked when appeared necessary in order to obtain more information, to remove the ambiguities regarding the given information, and to obtain an in depth understanding of complex experiences of participants. For instance, how did you perceive the required support from the family members and friends? What was your experience from receiving support from the healthcare providers? What was the impact of receiving social support on the process of your disease? Other questions were asked in terms of the participants' answers and at the end of the interview, the following question was asked: do you have anything to add? To answer any particular subject that is important to the participant and was not included in the interview. All of the interviews were audio-recorded and lasted between 27 and 76 min with the average of 45 min.

Data analysis
In order to analyze the data, the conventional qualitative content analysis method was used on the basis of the steps proposed in Graneheim's and Lundman's (2004) approach [20]. The qualitative data analysis was carried out using MAXQDA software, version 10, from the beginning of the study. In accordance with Graneheim and Lundman's approach, after several times of listening, the contents of all interviews were transcript verbatim into Microsoft Word files. Afterward, the transcripts were compared to the audio data to ensure their accuracy. In order to immerse themselves in the data, one of the researchers precisely reviewed the text of each interview for several times. Afterward, content analysis was started as follows to serve as the background for extracting codes. At first, meaning units were identified, then, meaning units were summarized and designated with appropriate codes, and the codes were placed in subcategories and categories on the basis of the similarities and differences between them. Finally, themes were extracted in accordance with the hidden concepts in the texts. In this stage, initial categories were discussed and reviewed by three researchers in order to generate the themes.
In order to reaching consensus, three researchers discussed and argued each other during several sessions. We focused on abstraction and interpretation during the analytic process [21]. We used both manifest and latent content for content analysis. Analysis of what the text says deals with the content aspect and describes the visible, obvious components, referred to as the manifest content. In contrast, analysis of what the text talks about deals with the relationship aspect and involves an interpretation of the underlying meaning of the text, referred to as the latent content [20]. In our study, first author (L.M) did primary data coding and corresponding author (A.F) checked them and any disagreements were discussed with another author (A.KM). Finally, all three researchers reached consensus about results and abstraction and interpretation of data. Table 1 illustrates the analytical process of data.

Rigor
In order to ensure the trustworthiness or methodological soundness and adequacy, the following criteria proposed by Lincoln and Guba (1985) were employed: credibility, transferability, dependability, and confirmability [22]. In this study, in order to ensure the credibility of data, we used prolong engagement with data, triangulation in data collection (face-to-face interview and memoing) and source (several participants), peer check, member check, spending enough time in collecting and analyzing data, and maximum diversity in participant selecting. For the transferability, the researcher tried to provide the conditions for using the findings in other social contexts by making an precise and indepth description of the context of the study, and analysis of the socio-demographic characteristics of the participants, and a clear explanation of the obstacles and limitations.
In order to ensure the dependability, research team discussed in several sessions about the collected data and content analysis process. An external audit was also used to determine if she would have a similar understanding of the data. Therefore, all stages of the process were described in detail from beginning to end, so that the external audit could perform the audit according to these documents. The researchers tried to ask all participants questions in the same field and record all the interviews and write them verbatim.
In order to check the confirmability, all stages of the research, especially the stages of data analysis process, were recorded in detail so that if the research reports, manuscripts, and notes were given to another researcher, both would extract the same findings. Continuous monitoring was performed from the beginning to the end of the research and comprehensive literature review was also delayed until data analysis.

Ethical consideration
This study was approved by the Ethics Committee of Urmia University of Medical Sciences (IR.UMSU.REC.1397-06-33-1820). Signed informed consent obtained and all documents kept private and confidential. All audio-taped interviews were reviewed by the researcher, and each participant was identified by a specific code number.
After completion of the process of analyzing, six categories were appeared including "creating an empathic atmosphere by the family and community," "being in relationship with others," "adapting to the disease," "giving meaning to life," "satisfaction with the role of healthcare providers," and "the impact of others support in fighting with the disease." Categories, subcategories, and some stories of the participants in this regard are expressed as follows.

Creating an empathic atmosphere by the family and the community
This dimension of social support was one of the common factors in the experiences of the participants. They stated that after being diagnosed with this disease, their family members, friends, relatives, and even the healthcare team were more empathic towards them and made it easier to endure the problem by their good behavior and support. The community and the family created an empathic environment by providing a happy life, strengthening their self-confidence, giving hopeful thoughts, highlighting the role of the patient in the family, physician's empathy with the patient, and encouraging to do exercise and recreational activities, which resulted in the appearance of the protective effects of social support in the patients and led to their emotional well-being.
One of the women said in this regard: "After my disease was diagnosed, we did more recreational activities because Another woman said: "The doctor's words brought me back to life. I was tired of this life and the doctor's words and actions helped me become more hopeful. I did not even want to go through surgery but the doctor persuaded me to do so" (p. 16).

Being in relationship with others
Diagnosis and treatment of breast cancer could cause various emotional and physical problems for the patients and affect the quality of their lives in many aspects. However, being in relationship with others is very important and can be effective in reducing some of their problems. This allows patients to break out of isolation and gain energy and spirit from their behavior and support by being in relationship with others. Patients expressed their experiences by associating with friends and relatives, not hiding their illness from others, better mood for recovery, and not being mentally preoccupied with the illness.
A participant explained: "All of the family and friends came to our home and we went to their homes and we have relationship with each other. This strengthened my spirits and everyone supported me. I had not hidden my illness from anyone. I had a good relationship with everyone." (p. 9).
Another woman stated: "We have relationship with each other. We have phone numbers of nurses and we contact each other and ask about each other's health. The nurses gave us their phone numbers and told us to call them if we had any problems and they told us what to do to feel better. Once I had a problem and I called my nurse and she guided me and my problem was solved. This made me feel healthy" (p. 1).

Effectively adapting to the disease
Effecting adapting to the disease requires time passage to carry out the required measures for diagnosing, treatment, and rehabilitation. Furthermore, a variety of factors impacted the acceleration of this process, which the women with cancer called them resilience and life satisfaction, hope to future, following the process of treatment, learning new skills for fighting the disease, coping with the disease, reducing of stress and increasing of the strength to fight the disease, and gradually revealing the disease to others.
A woman said in this regard: "We did not have enough information about our disease, but the doctors and nurses were very knowledgeable and we did what they told us to and achieved good results" (p. 8).
Another woman said: "I lost my hair after chemotherapy but I somehow dealt with it. I wore a wig, put on makeup and it really suited me" (p. 13).

Giving meaning to life
This dimension of social support was one of the common priorities among all of the participants. Women with cancer expressed that support from family and relatives following this disease gave a new meaning to their lives and they can recover sooner if they come to a new understanding of life goals and making efforts to achieve their goals. Women's experience included understanding the meaning of life despite the disease, spiritual development after the disease, understanding the beauty of life, better recognition of the value of life, contemplating on the creation and one's destiny, and setting goals for their lives and the future of their children and themselves.
An employed married woman described her experience as: "After my diagnosis, my husband supports me a lot and this made me have a better view of life. I decided with myself to prioritize my family after this, not my job; appreciate my health and that of my family and care about our fun and being together. Now I appreciate life more than before" (p. 17).
A married woman said: "After the operation and mastectomy, the family supported me and i saw that life has its own beauties that i passed by very simply during several years of my life. When i looked at people's faces, even the street had a different meaning to me. It was as if i had been born again. This led me to set good goals for myself and my children and i try to reach them" (p. 20).

Satisfaction with the role of healthcare providers
Women with breast cancer suffer from a wide range of social, psychological, mental, and physical symptoms during the process of diagnosis and treatment. On the other hand, treatment methods cause short-term and long-term complications in these patients. During the difficult conditions, the attitude and behavior of the healthcare providers had a considerable impact on the process of treatment of these patients. The satisfaction with the healthcare providers for fulfilling their roles was among the common experiences of the participants that were expressed as receiving enough information and explanations about the disease, the tendency to receive care form the fixed personnel, expressing gratitude to the members of health care team, and adherence to treatment due to the good behavior of the healthcare providers (Table 1).
A single woman said in this regard: "I told the nurses now that you put up with us, God will watch over you. I hope that you will never face any problem. You are supporting and tolerating us, you are taking care of us God bless you" (p. 1).
A widowed woman said: "My doctor was very good, made time for me, and answered all my questions and guided me. The nurses were very good with us and helped us to keep our spirit up and follow our treatment with more hope" (p. 18).

The impact of others support in fighting with the disease
According to the patients' statements, one of the effective factors in the recovery of women with breast cancer was the good cooperation of their family, friends, and peer group and their support. Relationship with other patients and survivors of breast cancer, talking to them about their experiences from this disease, was important and effective in finding methods to fight this disease and cope with the side effects of the treatment. Women's experience in this regard are as follows: the impact of the support of husband and family on recovery, the relationship with friends and peer group and participating in the social activities, boosting spirit and acceleration in the process of treatment, the role of the husband and family in praying and offering oblations for the patients' health.
One of the woman said: "I had a friend that had not opened her hair to me in 8 months of treatment. Because my hair was falling out and she thought I might see her hair and be upset. My friends treated me like this and cooperated. Their behaviors gave me the spirit to fight with the disease" (p. 5).
One of the women said: "In the hospital, I talked to women who were like me and had breast cancer and I used the experiences of others who had this disease. Every time I saw them, I told myself that I am not alone and there are other people like me and they have been cured. It gave me hope to fight with the disease" (p. 22).

Discussion
The present research aims at explaining the experiences of women with breast cancer from perceiving social support during their illness. One of its dimensions was creating an empathic atmosphere by the family and the community. In the study by Taghavi, it was revealed that social support is one of the vital aspects of cancer care, which can result in creating an empathic relationship for the patients. Besides, social support can increase a person's adaptation and capability to cope with chronic diseases such as cancer [23]. Fink et al. carried out a study that indicated that women with cancer have received support from their family, friends, and physicians [12]. Family was regarded as the most crucial support system for women suffering from breast cancer [24,25]. This similarity of the results demonstrated that social support was an effective factor in the emotional well-being of the patients with cancer and it was an interactive process that played a crucial role in patients' recovery by creating an empathic relationship.
Being in relationship with others was another dimension of social support among the participants. In a study conducted by Zhang et al., it was manifested that building a good interpersonal relationship with the women with breast cancer was viewed as fundamental for social support [15]. Therefore, providing social support through more effective and larger networks can help improve women's quality of life through instrumental, informational, and emotional support [26]. The effective presence of the family members, especially the husband, during the process of treatment was the most important supportive factor and helped the patient out of their isolation and mourning and highlighted the woman's role in the family as was before the illness [16]. Thus, it can be concluded that these patients' accessing to good interpersonal relationship during their disease and maintaining their relationships with others together with benefiting from the support and cooperation of the family members and relatives can have a considerable impact on their treatment process and recovery.
Another dimension of social support was the ability to adapt to the disease. Shoaa Kazemi. et al. in their research concluded that patients with breast cancer needed help to cope with their chronic disease. These people needed to learn new coping skills. This goal could be achieved when the fight and the reactions against the disease and its related problems were understood through raising awareness [27]. Aghabakhshi and Rashedi in their study indicated that positive social interactions and social support were one the effective factors on the capability to fight the disease in patients with cancer [28]. Social support is of paramount importance for women with breast cancer to deal with their situation [29]. The similarity of these results manifests the fact that patients with breast cancer need help to adapt to their chronic disease. Accordingly, receiving and strengthening social support from the family and friends has an effective role in this regard and helps patients to cope with their illness and fight it.
Giving meaning to life was another dimension of social support and the most predominant shared experience among women. The study by Fenwan revealed three main themes, which were the feeling of the value of life, the feeling of the relationship with nature and the superior creature, and the feeling of belonging to the community. Also, this study indicated that if women with cancer had a good family relationship, received the required social support, and the feeling of relationship with nature and the superior being, it could lead to having better well-being and this factor can have an impact on having a better understanding of the meaning of life [30]. In a qualitative study carried out by Azimi and Vaziri, it was revealed that understanding the meaning of life enhanced the tolerance threshold of a person. This helped people whose life had more meaning to properly confront the challenges and stresses of life. It also demonstrated that perceived social support can be effective in the strategies of coping with the pain in patients with cancer [31]. In our study, spiritual evolution following illnesses gave the women the strength to deal with the illnesses. Other studies have shown the spirituality and religion gave them the strength to accept their condition and provided hope to recover [32,33]. This similarity between the results indicated that in the process of treatment of the patients with cancer, the factor of the perceived social support and understanding the meaning of life should be taken into significant consideration in order to prevent the social, psychological, and physical side effects and increase the person's performance.
Another dimension of social support was satisfaction with the role of healthcare providers. Social support for providing healthcare for women with breast cancer will be invaluable through perceiving the personal experiences of these women. The healthcare providers should make an effort to create a therapeutic relationship based on trust and provide these patients with the supports they need in a professional manner [15]. Drageset et al. conducted research in which being perceived as a person, not a patient under treatment, was among the experiences of women with breast cancer. They were more willing to receive the care from the fixed personnel and they tend to have the feeling of uncertainty upon losing the professional support after treatment [34]. This finding also reported in other studies [32,35]. These results revealed the significance of receiving support from the healthcare providers, especially the nurses, in creating the feeling of recovery and improvement of the quality of life in these women. Thus, treatment-care staff should be aware of the importance of this issue and provide them with therapeutic support considering their individual differences and patients' experiences.
The impact of others support in fighting with the disease was another dimension of social support. In their research, Drageset et al. concluded that sharing the experiences with the family members and others as well as keeping an open mind regarding their illness, i.e., cancer, was important for most of the women with breast cancer. Many of the patients were using the internet to be in contact with the breast cancer institutions. Obtaining more awareness through other experiences helped them to feel better [34]. Zhang et al. conducted a study in which most of the participants emphasized that the fellow patients shared the medical information pertinent to cancer and treatment with them and the most important issue was that they could understand that they are not the only ones suffering from this disease [15].
A positive and supportive social environment in formal social support groups can allow cancer patients to reflect and discuss thoughts and feelings caused by cancer. This is the case in many [36]. In women with breast cancer, peer group support can promote their hope as a result of their participation in peer support groups to taking advantage of its direct benefits such as sharing experiences and participation in group discussions [37]. Accordingly, it can be concluded that receiving social support either from the family members or friends and even from the peer group and sharing their experiences can play a significant role in recovering from and fighting the disease.

Conclusion
Taking into account the results of the present study, women underwent various experiences from the perceived social support during breast cancer. Creating an empathic atmosphere by the family and community, being in relationship with others, adapting to the disease, giving meaning to life, satisfaction with the role of healthcare providers, and the impact of others support in fighting with the disease are among the experiences of the participants of the present research. In the present study, women received social support from their family members, friends, healthcare providers, and peer group. Receiving social support helps women to improve the quality of their life and it can lead to emotional well-being and acceleration of the process of their treatment and recovery. Boosting the spirit, enhancing a person's performance, learning the techniques of fighting this disease, and effective adaptation to the disease are of the other benefits of receiving social support in women who participated in this study. Taking into account the already mentioned items, the multidimensionality and significance of social support, and various roles of women in the family life and even the society, it appears that these patients should be provided with supportive measures by their family and the society.

Limitation
One of the limitations of the present study was the unwillingness of some women to participate in this study due to their reluctance to recall the bad memories from the past; however, this problem was solved, to some extent, by explaining the purpose of the study and emphasizing the confidentiality of the personal information of the patients. The findings of this study could be beneficial as a conceptual basis for explaining the concepts in other studies or designing intervention programs for providing women with more social support in oncology wards. Considering the qualitative design of the study and the small number of participants, the results of the present study cannot be generalized to all women with breast cancer. Therefore, it is suggested that in order to determine other aspects of social support on these people, other qualitative and quantitative studies should be carried out about these women and other patients suffering from cancer in order to use their results to plan the methods of providing the required support for these patients.