The results of this qualitative research were divided into four main themes and 19 sub-themes, which are described below. (Table No. 1).
The main category
Revaluation of life
Accepting a sick spouse
Understanding each other
Lowering couple expectations
Assigning and cooperating in tasks
Redefining couples interactions
Disregarding some issues
Prioritizing and replacing important issues
The emergence of some values
Optimization of the decision process
Participating in financial decisions
Participating in family decisions
Lifestyle upgrading decisions
Having secret agreements
Effective management of marital disputes
Expressing issues and problems to prevent conflicts in the family Expressing fears and worries
Apologizing to each other
Providing alternative solutions
Increasing empathy and sympathy
Accepting mistakes and forgiving each other
Focusing on the realities of life
Avoiding reacting and increasing the flexibility of using politics and resolving marital conflicts
Redefining pair interactions:
The first central theme was the redefinition of couple interactions consisting of sub-themes (accepting the patient's spouse, understanding each other, lowering the couple's expectations, assigning tasks), which are described separately below.
a) Acceptance of the patient's spouse:
Couples need to re-assess their couple interactions after the illness to achieve adjustments. For this reason, in the first place, a healthy couple makes every effort to accept their sick spouse and believe that their spouse is no longer a healthy person and may have physical and spiritual problems. In this regard, one of the participants said:
".... I have admitted that my husband is ill from now on ...." (Patient’s wife, F= 54y, I=7). This kind of acceptance and attitude to couples help accept the existing realities so that the disease leaves positive effects despite its inherent adverse effects. For instance, it increases the tolerance of couples and makes them accept each other with all defects.
b) Understanding each other:
The couple tried to understand each other better. In this regard, one of the participants said: "He gets angry, he gets upset, he loses his temper, and then calms down (Patient, F=41y, I=6)
Participant No. 7 stated in the field of patient perception: "... I understood him and then So was I ...." (Patient’s wife, F= 54y, I=7).
c) Lowered couple expectations:
Illness can also make unexpected differences in couples' expectations before and after the disease. So, the couples try to lower their expectations to an acceptable level. In this regard, one of the participants said: "... Expectations before the disease were utterly different from those after the disease. Before the illness, our least expectation was to make ends meet and have a relatively luxurious life, but then I lowered my expectations (Patient’s wife, F= 50y, I=5)
d) Assignment of tasks and cooperation:
Other changes that took place with positive trends between the couples and somehow improved the interactions between the couples include the division of tasks and cooperation with each other. In this regard, participant No. 11 stated: "... I do the work of the shop, but he does the shopping for the shop[…] After the illness, we helped each other more than before. (Patient’s wife, F= 35y, I=11)
Participant No. 12 stated, "we had divided the tasks among ourselves, and we did not have conflicts and disputes ..." (Patient’s husband, M=66y, I=12).
Revaluation of life:
Couples began to re-evaluate life after illness and in the process of creating new cycles to achieve marital adjustment. In this complex and tortuous process, couples jointly examined the inner values of their lives. So, what used to be valued for couples lost its value after the illness, and couples tried to have another alternative. So other issues become valuable.
a) Disregarding some issues:
Having sex is one of the issues that lose its value after the disease, especially in couples who have been living together for several years. Couples tried to overlook the shortcomings due to illness. This case was more common in couples that the husband had the disease and the wife had decreased sexual desire due to frequent births and menopause. In this regard, one of the participants said: "... we had already sexual relationship frequently, but it loses its importance after a certain age (Patient's wife, F=50y, I=5). Participant 9 stated in this regard: "... sexual intercourse becomes a routine and repetitive work ..." (Patient's wife, F=50y, I=9).
The reduction of the couple's sensitivities and the insignificance of some issues were related to sexual intercourse and many other issues that were earlier important for the couples and sometimes even caused conflicts between the couples after the disease. Another participant said: "He used to inform me after making a decision, and it caused conflict, but now I disregard it» (Patient's wife, F=47y, I=3)
b) Prioritizing and replacing more important issues.
Couples began to prioritize and replace important issues in the process of revaluation in life. Thus, to maintain and sustain their lives, they replaced the less important issues with more valuable and important ones.
The marital relationship is one of the main issues whose priority and importance in the couple's life had changed and replaced with emotional attachments. In this regard, one of the participants said: "... Well, after 30 to 40 years of partnership, you get used to being with whose absence is annoying. So it brings love, no matter sex exists or not" (Patient's wife, F=50y, I=5). In this regard, another participant said: "... I try to entertain myself, because when a person is alone at home, he may think more about these issues. Now I found a part-time job, working as an accountant. Doing so will take my mind off this issue to some extent ..." (Patient's husband, M=62y, I=13)
c) Emergence and prioritization of some values
In the process of re-evaluating life after the illness, some issues had been highlighted and bold for couples. In this way, the couples thought about issues and cases after the disease they had never regarded before. However, the couple's presence and absence became important after the incidence of disease, especially in confrontation with death and the problems of the disease. They were concerned about what would happen to the other if one of the couples was not there. One of the participants in this regard said: "... We think about issues that we did not care about before, what would happen if one of us was nor there (Patient's wife, F=50y, I=9)
The couples realized the value and importance of their spouse's presence in their married life and considered it more important and valuable than anything else. In this regard, another participant said: "... after the illness; he figured out that just his wife accompanies with him, not sisters and brothers..." (Patient's wife, F= 50y, I=5). Participant 4 said in this regard: ".... until the incidence of the illness, we were constantly trying to interfere in each other's work, but the illness made me value him at least
...." (Patient, M= 57y, I=4).
Optimization of the decision process:
Other results of this qualitative study include the optimization of decision-making processes in couples after illness, which is described in the following sub-themes.
a-Participation in financial decisions:
After the illness, due to the disruption of the family structure, changing roles and responsibilities, financial and economic problems, and the decision-making processes in the family had changed. In this way, the couple made changes in their financial decisions. They included reducing unnecessary living costs, participating in financial decisions, and considering patient treatment costs. In this regard, one of the participants said: "... I had to reduce family expenses, spend less, wear less and eat less ...." (Patient's wife, F= 50y, I=5). Another participant said: ".... I often reduced the costs so that we would not have difficulty in paying for the treatment costs ...." (Patient's wife, F=47y, I=3)
b- Participation in family decisions:
After myocardial infarction, couples changed their decision-making styles and began to involve each other in family decisions. In this regard, participant No. 11 stated: "... we usually make decisions with each other, previously he made his mind alone…” (Patient's wife, F=35y, I=11)
c- Lifestyle upgrade decisions:
The couples began making decisions that improved their lifestyles. They began to observe health issues and change some habits in life. In this regard, one of the participants said: "... Well, we tried hard to make life last; you have to change lost of habits, first of all, living habits. You try to be less greedy, less angry ... "(Patient, M=57y, I=4) Or participant number ten said: "... if I did not observe a healthy lifestyle, I would lose my life ..." (Patient, M= 75, I=10).
d- Having secret agreements:
The couples sometimes made secret agreements to optimize their decision-making processes; they acted at the family level based on these agreements. In this regard, participant No. 13 stated: "...We made the decisions together, but the lady has the last say" (Patient’s husband, M=62y, I=13)
Effective management of marital conflicts:
The present study showed that couples managed and resolved their marital conflicts more effectively to achieve marital adjustment after the illness. The conflicts are rooted in the past of couples' lives. Thus these conflicts were managed effectively after the disease. Although functioning and resolving conflicts varied from couple to couple, but in some cases, there were similarities between the methods used by the couple, which are as follows:
a )Expressing issues and problems to prevent conflict in the family:
One of the things couples did after the illness was beginning to express problems because of feeling intimate. Some cases were rarely seen among couples before the disease but became more pronounced after the disease. It is worth noting that expressing problems and discomforts at the beginning of disputes reduces the misunderstandings between couples and, on the other hand, makes couples get closer and increases marital intimacy between them. Couples used different ways to express problems. For example, one of the participants in this regard said: "... Whenever there was a problem, my lady would express the reason for her sadness directly in a not and give it to me..." (Patient’s husband, M=66y, I=12).
b) Expressing fears and worries:
Couples showed a strong desire to share their fears and anxieties after illness so that they could respond to their inner need to get comfort and relief from their spouse. In this regard, participant 7 stated: "... My husband said that what would I do if he died? I asked him to stop thinking about him ..." (Patient’s wife, F=54y, I=7).
The apology was another method that couples used to manage marital conflicts and solve their marital problems effectively. In this way, they no longer looked at everything through their lens, and sometimes they looked at their interpersonal problems through another lens. So, if they felt that they were judging unilaterally or the viewpoint of another party was better than theirs, they accepted the truth, improved the relationship, went further, and apologized. However, this case was more common among couples where the dominant person never admits their mistakes or even did not consider their spouse's opinion in many cases before the illness. In this regard, one of the participants said: "... I'm upset now, he guesses from my facial expression that I was upset, if he understands that I'm upset by his actions, he will apologize ..." (Patient's wife,F= 50y, I=5)
Participant 14 said: "... Later that he returned to life; he apologized because I was upset […] We have not had many fights and conflicts since that day ..." (Patient's wife, F= 35y, I=11).
d) Providing alternative solutions:
Another problem that has continually arisen between couples was that one of the couples played a pivotal and dominant role in making the decisions. Sometimes the husband did not ask his wife's opinion on the issues, which would cause problems after the other person understood the issue. For this reason, couples tried to make changes in their behaviour and attitudes after the illness. One of the main changes in the couple's relationship increasing advice and consultation. In this regard, participant 7 stated: "He lets me know about everything he wants to do, he asks my opinion and consults with me ." (Patient's wife, F= 54y, I=7)
e ) Increase empathy and sympathy:
Couples always tried to accompany each other in marital problems, settle life's difficulties, always count on each other and support like two loyal friends. They tried to explore their common concerns appropriately and find a solution for each other. Couples were sensitive to each other's feelings and emotions, so if one of them was upset and worried, the other person would do his best to withdraw the grief, sadness, and worry. In this regard, one of the participants said: "...I did not feel well so that my wife was worried about me … " (Patient’s husband, M=62y, I=13)
f) Accepting mistakes and forgiving each other:
In addition to empathizing with marital problems, couples have used other strategies to resolve marital disputes effectively. When there is a problem between couples, they usually try to inspect the aspects of the issue and take the blame if they have misunderstood part of the problem. For this reason, the couples had given up their false pride and consider their partner right in addition to accepting their mistakes, an issue that was rarely observed at the beginning of married life and the couple's lack of acquaintance with each other. He says, "Yes, you are right. You helped me with financial issues I was wrong" (Patient's wife, F= 50y, I=5)
g) Focusing on the realities of life:
To effectively resolve marital conflicts, couples sometimes found the only effective way to overcome marital conflicts is to focus on the realities of their lives and thus make their spouse informed of their mistake. In this regard, one of the participants said: "I told him that I was not your captive; I am your wife, not your servant..." (Patient's wife, F=50y, I=5). Participant No. 14 also commented: "... Early in my life, we lived in my father in law' s house, and I was upset about it. I wanted to be independent. I told my husband and he conveyed it to his parents, they got upset, Now were are detached but adjacent to them” (Patient's wife, F=35y, I=11)
h- Avoiding rush reaction and increasing the resilience:
The couples tried to increase their tolerance level after the illness and did not show emotional and rush reactions due to the increased tolerance in marital conflicts. In this regard, participant No. 11 stated: "... they stand and tolerate, even though it is difficult” (Patient's wife, F=35y, I=11)
i- Using politics and resolving marital conflicts:
The use of politics was another thing that couples used to resolve their marital disputes. In this regard, the participant of number thirteen stated: "... Thank God, my wide is a tactful woman, if there was a conflict between her family and me, she settled it tactfully” (Patient’s husband, M=62y, I=13)