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Volume 10, Issue 1 (2022)
Health Educ Health Promot 2022, 10(1): 43-50 |
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Received: 2021/08/24 | Accepted: 2021/10/3 | Published: 2022/01/24
Received: 2021/08/24 | Accepted: 2021/10/3 | Published: 2022/01/24
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Mokhtari L, Feizi A, Khalkhali H, Khorami Markani A. Lived Experience of Women Suffering from Breast Cancer about Meaning of Life: Evidence from Society of Iranian Women. Health Educ Health Promot 2022; 10 (1) :43-50
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1- Department of Nursing, School of Nursing & Midwifery, Urmia University of Medical Sciences, Urmia, Iran
2- Patient Safety Research Center, Urmia University of Medical Sciences, Urmia, Iran
3- “Patient Safety Research Center†and “Department of Biostatistics and Epidemiologyâ€, Urmia University of Medical Sciences, Urmia, Iran
4- Nursing Department, Khoy University of Medical Sciences, Khoy, Iran
2- Patient Safety Research Center, Urmia University of Medical Sciences, Urmia, Iran
3- “Patient Safety Research Center†and “Department of Biostatistics and Epidemiologyâ€, Urmia University of Medical Sciences, Urmia, Iran
4- Nursing Department, Khoy University of Medical Sciences, Khoy, Iran
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Introduction
As the main cause of death in women suffering from it [1], breast cancer is considered the main problem in the present century [2]. In 2020, this disease will account for 11.7% of all diseases [3]. Also, 76% of the prevalent cancers in women in Iran are pertinent to breast cancer [4]. Breast cancer and its treatments cause significant damages to various aspects of women’s life [5]; women are suffering from a vast range of symptoms pertinent to it from physical, mental, spiritual, and social aspects [6]. Despite the positive management and treatment process of patients, breast cancer still affects the quality of life upon diagnosis, during the treatment process, and even after the complete recovery [7]. Recent studies indicate that the meaning of life is an important preventive factor in emotional instability and guarantees their health while impacting the quality of life [8].
The meaning of life and its importance are fundamental factors in having a good and happy life [9]. The meaning of life is a controversial issue since different types of life necessitate different meanings thereof [10]. The meaning of life could be defined as people’s understanding of their lives or the extent they care about it [11], people's feelings about having a goal in their life, or spending time and energy to accomplish those worthwhile goals [12]. Viktor Frankl describes the meaning of life as the manifestation of values based on creativity, experience, and attitude [10].
During recent decades, a special emphasis has been placed on the importance of the meaning of life in patients suffering from advanced diseases such as cancer. Cancer diagnosis could challenge a person’s plans for the future. Considering that this illness is capable of threatening life and causing death, the importance of the meaning of life is doubled in cancer [13-16].
Existence and feeling the meaning in life serve as the key to solving the problems and trigger positive reactions in individuals [17]. The meaning of life is associated with mental and intellectual health, life quality, hope, optimism, self-efficacy, and self-confidence [11]. Nurses should be prepared to help patients and their families cope with the illness and the pain besides finding meaning in these experiences [18]. Dictating the belief that life has a meaning that will also exist in the future could support fighting fleeting bad feelings, boredom, and disappointing thoughts [19].
Considering that the meaning of life is an abstract, subjective, and multidimensional concept, qualitative research seems necessary to describe the experience of the meaning of life in women with breast cancer and find its nature and dimensions. Qualitative research is of great help in performing a deep and comprehensive investigation into any phenomenon, especially in the research lacking systematic information, and the existing quantitative research methodologies could not comprehensively investigate the phenomenon’s nature. Conventional content analysis is generally used in studies for describing a phenomenon [20]. Content analysis is one of the analysis methods in qualitative studies, by which data are summarized, described, and interpreted [21, 22].
Studying the scientific texts about the meaning of life in women with breast cancer, especially in Iran, indicates that few quantitative and no qualitative studies are carried out on this subject. Therefore, in the present study, individuals’ experiences with breast cancer were explained through conventional content analysis.
Participants and Methods
This qualitative study was conducted in five teaching hospitals and oncology centers affiliated to Urmia University of Medical Sciences on patients referred to these centers for surgery, chemotherapy, and radiotherapy. Data collection took place during spring and winter 2019. The women meeting the eligibility criteria were selected based on the purposive sampling method (N=22). The maximum number 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. The inclusion criteria for participating were being Muslim, diagnosed at least six months ago, and completing the written informed consent form. The exclusion criteria were patients’ death, disease aggravation, and unawareness of their disease.
The data were collected through semi-structured interviews using an interview guideline consisting of open-ended questions. For instance, one of the questions asked from the participants was: Would you please tell me about your experience on the meaning of life during the disease? For each section of the interview, the probing questions were asked when it appeared necessary to obtain more information, remove the ambiguities regarding the given information, and obtain an in-depth understanding of the complex experiences of participants. For instance: What are your goals in life? What does life mean to you right now? How did the illness affect your attitude towards life? What do you do to improve the meaning of your life? Other questions were asked in terms of the participants’ answers. At the end of the interview, the following question was asked to answer any particular subject important to the participant that was not included in the interview: Do you have anything to add?
After obtaining a permit from the Research Council and Ethics Committee, Urmia University of Medical Science, before the interview, written and verbal information about the study was given, and written informed consent was attained from all participants. Their participation was voluntary, and they had the right to withdraw from the study at any stage. Interviews were conducted to discover and describe the dimensions of the meaning of life based on the lived experience of women with breast cancer. After obtaining the willingness to participate, an appropriate place and time were arranged for the interview. Data were collected via face-to-face interviews individually by the first author (26 interviews with 22 participants) and in a private room. All the interviews were audio-recorded and lasted between 27 to 76 min with an average of 45 min.
The conventional qualitative content analysis method was used to analyze the data based on the steps proposed in Graneheim & Lundman's approach [23]. The qualitative data analysis was carried out using MAXQDA software ver. 10) from the beginning of the study. Following Graneheim & Lundman's approach, after several listening times, the contents of all interviews were transcribed verbatim into Microsoft Word files. Afterward, the transcripts were compared to the audio data to ensure accuracy. To immerse themselves in the data, one of the researchers precisely reviewed the text of each interview several times. Subsequently, content analysis was started to serve as the background for extracting codes. At first, meaning units were identified; then, meaning units were summarized and designated with appropriate codes. One thousand eighty initial codes were extracted, then these initial codes were assessed based on similarities and differences, and 389 secondary codes were extracted. The first author reviewed the interviews, collected qualitative data, analyzed manifest and latent content, and extracted the codes. Then the researchers compared the codes within several sessions, discussed similarities and differences, and interpreted the latent content. After this stage, the codes were placed in subcategories and categories based on the similarities and differences. A category describes the content on a manifest level, with a low degree of interpretation and varying abstraction [24]. Finally, the research team increased the degree of abstraction and interpretation, and themes were extracted. A theme is a unifying ‘red thread’ running through several categories that bring meaning to the phenomenon under study and its various manifestations [24]. In this stage, the research team discussed subcategories and categories about the research aim and the concept under review to generate the themes. To ensure the trustworthiness or methodological soundness and adequacy, the following criteria proposed by Lincoln & Guba were employed: Credibility, transferability, dependability, and conformability [25]. Thus, the research was conducted by prolonged engagement with the data, peer check, member check, external audit, simultaneous analysis of the data, observing the maximum diversity in the participants, bracketing, constant supervision from the beginning up to the end of the research, elaborating on the manner of interviewing and data analysis, and precise and in-depth description of the research process.
Findings
The mean age of the participants was 48.18 years old, and their ages ranged from 30 to 79 years. Also, 82% of women were married (n=18), 4.5% were single (n=1), 9% were widow (n=2), and 4.5% were divorced (n=1). In terms of education, 18.2% of the women were illiterate (n=4), 13.6% had completed high school (n=3), 45.5% of the women had a diploma (n=10), and 22.7% of the women in our study were university graduates (n=5). As far as the occupation was concerned, 77.3% of the study participants were housewives (n=17), and 22.7% were employed (n=5).
Upon completion of the analysis, two themes were extracted; Categories in the “development in the process of life” included seven categories and 18 subcategories, and categories in ”the attempt to promote spiritual well-being” included the three categories and six subcategories (Table 1).
Table 1) Subcategories, categories, and themes indicating the meaning of life in women suffering from breast cancer
![src=./files/hehp/images/HTML_Publish/55095/55095-T_1.png]()
The theme of development in the process of life
Development in life was the main theme attained from the interviews. All the patients stated that cancer caused changes and developments in their lives, some positive and others negative, but for a short period. Categories and some stories of the participants in this regard were expressed as follows:
Feeling the change in life routine: The feeling of change in the life routine was one of the differentiating factors in the mental experiences of the interview participants. Among some women, this illness led to positive changes in their daily life, such as enjoying life despite the illness, gaining a better insight into people around them, feeling that they were reborn after the illness, and having a sense of empowerment. This illness led to negative changes in some women’s lives, such as anxiety and helplessness, temporary feeling of despair in life, hopelessness caused by the illness, and uncertainty regarding the complete recovery of the illness.
The participants stated that:
“I always fulfill my tasks despite the illness. I go to the park, parties, and weddings. I try to entertain myself. I always do my household chores” (P 13). “I try to enjoy every moment of my life” (P 5).
Achieving a better recognition of the life value: All women expressed that life became more valuable to them after being diagnosed with breast cancer, and they tried to do things that made them enjoy their life more than before. In this category, the following codes appeared: life appreciation, settling family disputes, maintaining joy in family, appreciating the health of their family and their own, understanding beauties of life, and having a better perspective on life.
The following were the statements made by some of the participants:
“Thanks to God, my husband treats me more nicely after my illness. He has changed a lot. Before my illness, he told me that he would divorce me; but after the illness, he never says anything inappropriate” (P 8). “My life became much
better after the illness. For instance, I felt more hopeful about how considerate my husband is and how much my husband and children care about me” (P 14).
Having life satisfaction despite the illness: Diagnosis and treatment of breast cancer could cause various problems for patients and their families and affect the quality of their lives in many aspects. Life satisfaction was manifested in some of the interviewees in the form of experiences such as lack of life satisfaction, becoming more content, and inability to change life and destiny. Some of them said:
“Life is like a road, it has ups and downs, but we have to endure it. I have no expectations of people. Everything is a lie, but death” (P 16). “Before my illness, I always thought about unimportant things, things like other people’s lives, and I wanted my life to be like theirs, but now, no way. I swear it is still like that; health is more important than anything. The important thing is that be happy with your own family” (P 8).
Hoping for and accepting that the illness will end: Hopefulness and achieving inner peace were among the priorities of patients with cancer, especially when witnessing the death of others. Hoping for and accepting that the illness would end were the differentiating factors in the mental experiences of women at the beginning of the illness when they might feel despair and are afraid of death. On the other hand, some women were strong right from the beginning of the illness. Some women expressed their experiences as follows:
“I was really strong, I knew it was nothing, and it will pass by. I knew that this illness was not dangerous and scary” (P 13). “I have a hopeful attitude. I look at life with hope, and the beauties that I have been overlooking now start to make sense to me. I try to enjoy every moment of my life” (P 5).
Trying to cope with the illness: Coping with cancer happens over time. In addition to the passage of time, other factors could affect this process, such as keeping patients’ spirits up, support of friends and family, and relationship with God. Some women participating in the interview described this process with concepts like getting used to the illness over time, being strong, and accepting the illness:
“I was shocked after being diagnosed with the illness. I cried a lot, and I thought that I would die. But after a while, I felt better, and I told myself that I have to be strong and try to fight this illness for the sake of my children” (P 18). “I did not know what to do, but God gives you the strength to fight it” (P 22).
Tolerating the pain and suffering of the illness: Breast cancer causes various problems for women suffering from it, such as chemotherapy, mastectomy, change in the mental self-image, and physical and mental problems which result in dysfunction both at home and at work. Tolerating the pain was easier for some women with a few problems, but some women had more severe problems. Some stories of the women’s experiences in this regard were expressed as follows:
“I still get nauseated when I see the medications. After each chemotherapy session, my body is painful, and I feel like my bones are breaking. I have lost my hair” (P 15). “I care too much about my body image, more than myself. After I lost my hair and removed my breast, I became really upset. It upsets you because it is a part of our femininity. If it was my stomach or intestine, it could not have the same impact” (P 21).
Worrying about the children’s future: All married women who participated in this study were worried about their children’s future, which is one of the major obsessions of married women. In a manner that they all wished to get better for the sake of their children and God to bestow them with a new life to see their children’s happiness. Some women expressed their experiences as follows:
“I am worried about my children, about taking care of them” (P 6). “I only think about my children, and I told myself how they are going to live after I’m dead? Can they live with a stepmother?! I am praying God to give me another life to see my children’s happiness” (P 17).
The theme of the attempt to promote spiritual well-being
Another theme attained from the interviews is the attempt to promote spiritual well-being. All participants in the study believed that their relationship with God was improved due to cancer, in a way that after being diagnosed with this illness, they felt closer to God. Categories of this theme and some stories of the women’s experiences in this regard are expressed as follows:
Personal belief: Personal belief creates an indescribable joy in you, a kind of joy that is not materialistic and results from the relationship with a transcendent power. Thanking God, surrendering self to God, believing that God is the Most Compassionate and the Healer of all, the feeling of spiritual peace, being satisfied with God’s will, and praying for self and others are the codes that appeared in this categories. Some of the experiences of these women about this are described as follows:
“I always thank God, and this spiritual relationship gives me inner peace, and I feel that I am closer to God more than anything” (P 5). “I started reading the Quran, I could not read it well, but I memorized some short Verses, this makes me feel peace on the inside” (P 4).
Spiritual contentment: Spiritual contentment is a process that is identified by appealing to God, feeling secure in God’s love, feeling closer to God, and is an important factor in human beings’ salvation. Spiritual contentment in some women manifested itself with experiences such as thinking of the illness as a Divine Test, believing in the reliance on God, stability in religious beliefs, rejoicing in carrying out good deeds, and the impact of true dreams in recovery. Some of the participants stated the following for this subject:
These are Divine Tests, and God is nagging you to see if you will leave Him or not? To see if I will forget Him? But I would never forget God, not even for a second” (P 1). “Reliance on God gave me the power to complete my treatment” (P 18).
Religious acts: All women who have breast cancer who participated in this study stated that after being diagnosed with the illness, they improved their relationship with God by carrying out religious acts. Women expressed their experiences with concepts such as improving the relationship with God to fight the illness, carrying out religious acts for recovery, offering oblations for recovery, improving the relationship with God after recovery, and believing that God will never forget them.
“After breast cancer diagnoses, I improved my relationship with God” (P 5). “God makes you sick because He wants to hear your voice. This illness made me think that God is teaching me like a mirror. I say to myself that God made me sick to hear my voice every day. I raise my hand, asleep and awake, and call God’s name and I tell God that you are the Savior, please save me, I say that O God you are my Healer” (P 1).
Discussion
In the present study, one of the experiences of women who have breast cancer regarding the meaning of life was the change in their life routine. In the study carried out by Bernard et al., it was found that the meaning of life is a strong preventive factor against psychological distresses at the end of life in the patients needing palliative care [17]. The meaning of life operates as a moderating factor against physical damage and hastens death wishes in patients who have advanced cancer [23]. Women who have breast cancer who possess a higher meaning in life and have the goals pertinent to the meaning show more resistance against cancer, and their immune systems operate better [26]. This association indicates that understanding the meaning of life could help patients suffering from cancer promote their quality of life, and cultural and social differences have no impact.
Achieving a better recognition of the value of life was one of the subjects that the participants had experienced from the meaning of life. Damasio et al. showed that the meaning of life has an important role in the positive performance of human beings; for instance, the meaning of life is linked to the quality of life, hope, optimism, self-efficacy, and self-confidence [11]. Nowadays, in palliative care, the meaning of life is one of the main factors in psychotherapeutic interventions. Even patients with limited life expectancy can still consider life as valuable [13]. This association of the results demonstrates that the meaning of life is a fundamental element in the psychological-emotional well-being of humans and could be pertinent to various dimensions of personality, mental and physical health, compatibility, and adaptation to stresses on a systematic basis.
Another category was the satisfaction of life despite the illness. Tork Moghadam indicated that confusion and diminution of the meaning in life demonstrate the decrease in the feeling that life is valuable and expresses the belief that life is a negative experience. In this case, there will be no encouragement to pursue the important goals, and people will be confused about themselves and their lives [19]. Diagnosis and treatment of cancer cause dysfunctions, including physical image, stress,
anxiety, hopelessness, weariness, fear of death, and incapability [27]. The association of results could be due to adaptation based on the meaning of life after being diagnosed with an incurable disease.
Hopefulness and accepting the ending of the illness were another common experience amongst the women. Halama & Dedova found that understanding the meaning of life could increase the tolerance threshold of a person, and having a meaning in life could result in welfare and life satisfaction [28]. This helps people who have more meaning perfectly confront life challenges and stress [29]. Therefore, the meaning in life could create positive feelings in people, which effectively confronts the feeling of lacking purpose in life and despair.
Trying to cope with the illness was an important category of this study; the role of spouse, family, and friends is of great importance. Sources of social support could play a determinant role in the adjustment process with the life crises [30]. The coordination and adaptation aspect of the meaning of life is made of positive thoughts and mental status, which creates a feeling of peace, security, and comfort in the mind [19]. Thus, finding meaning in life is one of the positive factors for helping patients cope with the severe conditions of the illness.
Tolerating the pain and suffering of the illness was among other women’s experiences. In the study carried out by Mozaffari et al. regarding children who have cancer, it was found that children experience more pain due to the nature of the illness [31]. Travelbee, in the “Middle-Range Theory of Spiritual Well-being in Illness,” argued that “a person’s attitude regarding illness and pain is a person’s attitude toward suffering ultimately determines how effectively he copes with illness” [18]. Enhancement of the meaning in life helps a person overcome conflicts and results in improving personal life satisfaction. Seemingly, this feature of meaning plays an important role in helping people overcome situations filled with conflict and tension.
Worrying about the children’s future is one of the most obvious categories of the study and amongst the common experiences of all women. In the study conducted by Vaziri et al., the results indicated that the increase in the awareness of mothers who have cancer regarding the necessity of the mother-child relationship could create a more positive perspective of mothers to the mother-child relationship [32]. A mixed-method study was conducted by Baltisberger et al. in the United States. This study showed that “bent but not broken” was a powerful metaphor that mothers during chemotherapy for breast cancer used for their duties towards the children [33]. Adams and Dell‘s study indicated that women who choose mastectomy are most worried about their children as a mother [34]. The association of these results demonstrates that when facing a personal problem, all mothers, from all cultures and societies, worry about playing their different roles, such as a maternal role for their children, and try to play this role in the best way possible.
The next category is Personal belief. In the study carried out by Mozaffari, some participants stated that they always had faith in God and deeply believed that God determined life to be this way and living in this world should be by God’s will [31]. Karekla & Constantinou argued that in adults who have cancer, believing in God and religious beliefs, in general, is an important aspect in coping with cancer [35]. The association of the results indicates that in the experience of living with cancer, personal belief and believing in God is one of the notable and important aspects of a healthy life.
Spiritual contentment is amongst another experience of women about the meaning of life. Spiritual beliefs are embodied in every aspect of a person’s health, direct daily habits and are the source of support, power, and recovery [36]. “Life, as a groundwork of Divine Tests” is one of the main themes of the qualitative research carried out by Mozaffari et al. and shows the existent of a kind of deep belief in God in the children who have cancer [31]. Joulaee et al. carried out a study concerning the lived experience with breast cancer. The findings of this study showed that patients felt closer to God more than ever, and religious beliefs helped them obey God and cope better with their conditions illness [37]. Therefore, believing in God and relying on Him serves as an important and powerful response for the meaning of life. It could be considered a positive mechanism for adaptation and coping with the illness.
Another category is carrying out religious acts. The personal relationship with God and the Higher Beings is one of the aspects of spiritual well-being [38]. Understanding the goal and the meaning of life is the pivotal part of spirituality in the Holistic Nursing Theory, which demonstrates the wholeness of individuals and their relationship with the Higher Power [39]. Halligan, in his study, demonstrated that relationship with God serves as the spiritual need in Christian American patients with cancer [40]. This association of results indicates that Theology is the basis of all religions, and cultural differences have no impact. Human beings in any religion rely on God in any severe condition and appeal for God’s help to overcome their problems.
One of the limitations of our study was the unwillingness of some women to participate in this study due to their reluctance to recall the bad memories from the past. The findings of this study could be beneficial as a conceptual basis for explaining the concepts in other studies and/or designing spiritual intervention programs and even carrying out palliative care in oncology wards. Because this study was carried out in one region of a country and it could not represent all women who have cancer and taking into account that very few studies have been carried out concerning the meaning of life in women with cancer, thus, it is suggested that to determine other aspects of spiritual life in these people, other qualitative and quantitative studies should be carried out about these women and other patients who have cancer to improve the quality of life and find the meaning of life. Moreover, educational courses should be held, and the necessary support should be provided.
Conclusion
The meaning of life in women with breast cancer is a multidimensional concept. The development in the process of life and the attempt to promote spiritual well-being are the most predominant experiences. Understanding the meaning of life can promote their spiritual well-being and quality of life. Considering that women carry out important roles in the family and even in society, the health system should take necessary measures to improve the meaning of life in these patients, support them and build a proper relationship with these patients.
Acknowledgments: The authors would like to express their deepest gratitude to the Vice-Chancellor for Research of Urmia University of Medical Sciences, all participants of the study, and estimable colleagues, especially in Omid and Imam Khomeini Hospital of Urmia and Shahid Madani Hospital of Khoy.
Ethical Permissions: The study was approved by the Research Council and Ethics Committee of the Urmia University of Medical Science [IR.UMSU.REC.1397.277].
Conflicts of Interests: This research is part of a Ph.D. thesis, and all authors declare that they have no competing interests. Also, the funding body had no role in the study’s design, data collection, analysis, interpretation of data, or writing the manuscript.
Authors’ Contribution: Mokhtari L (First Author), Introduction Writer/Main Researcher/Discussion Writer (50%); Feizi A (Second Author), Statistical Analyst (20%); Khalkhali HR (Third Author), Assistant Researcher (10%); Khorami Markani A (Fourth Author): Methodologist (20%)
Funding/Support: We did not receive any grant from funding agencies in the commercial or not-for-profit sectors. This project was supported by the Research Deputy of Urmia University of Medical Sciences.
As the main cause of death in women suffering from it [1], breast cancer is considered the main problem in the present century [2]. In 2020, this disease will account for 11.7% of all diseases [3]. Also, 76% of the prevalent cancers in women in Iran are pertinent to breast cancer [4]. Breast cancer and its treatments cause significant damages to various aspects of women’s life [5]; women are suffering from a vast range of symptoms pertinent to it from physical, mental, spiritual, and social aspects [6]. Despite the positive management and treatment process of patients, breast cancer still affects the quality of life upon diagnosis, during the treatment process, and even after the complete recovery [7]. Recent studies indicate that the meaning of life is an important preventive factor in emotional instability and guarantees their health while impacting the quality of life [8].
The meaning of life and its importance are fundamental factors in having a good and happy life [9]. The meaning of life is a controversial issue since different types of life necessitate different meanings thereof [10]. The meaning of life could be defined as people’s understanding of their lives or the extent they care about it [11], people's feelings about having a goal in their life, or spending time and energy to accomplish those worthwhile goals [12]. Viktor Frankl describes the meaning of life as the manifestation of values based on creativity, experience, and attitude [10].
During recent decades, a special emphasis has been placed on the importance of the meaning of life in patients suffering from advanced diseases such as cancer. Cancer diagnosis could challenge a person’s plans for the future. Considering that this illness is capable of threatening life and causing death, the importance of the meaning of life is doubled in cancer [13-16].
Existence and feeling the meaning in life serve as the key to solving the problems and trigger positive reactions in individuals [17]. The meaning of life is associated with mental and intellectual health, life quality, hope, optimism, self-efficacy, and self-confidence [11]. Nurses should be prepared to help patients and their families cope with the illness and the pain besides finding meaning in these experiences [18]. Dictating the belief that life has a meaning that will also exist in the future could support fighting fleeting bad feelings, boredom, and disappointing thoughts [19].
Considering that the meaning of life is an abstract, subjective, and multidimensional concept, qualitative research seems necessary to describe the experience of the meaning of life in women with breast cancer and find its nature and dimensions. Qualitative research is of great help in performing a deep and comprehensive investigation into any phenomenon, especially in the research lacking systematic information, and the existing quantitative research methodologies could not comprehensively investigate the phenomenon’s nature. Conventional content analysis is generally used in studies for describing a phenomenon [20]. Content analysis is one of the analysis methods in qualitative studies, by which data are summarized, described, and interpreted [21, 22].
Studying the scientific texts about the meaning of life in women with breast cancer, especially in Iran, indicates that few quantitative and no qualitative studies are carried out on this subject. Therefore, in the present study, individuals’ experiences with breast cancer were explained through conventional content analysis.
Participants and Methods
This qualitative study was conducted in five teaching hospitals and oncology centers affiliated to Urmia University of Medical Sciences on patients referred to these centers for surgery, chemotherapy, and radiotherapy. Data collection took place during spring and winter 2019. The women meeting the eligibility criteria were selected based on the purposive sampling method (N=22). The maximum number 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. The inclusion criteria for participating were being Muslim, diagnosed at least six months ago, and completing the written informed consent form. The exclusion criteria were patients’ death, disease aggravation, and unawareness of their disease.
The data were collected through semi-structured interviews using an interview guideline consisting of open-ended questions. For instance, one of the questions asked from the participants was: Would you please tell me about your experience on the meaning of life during the disease? For each section of the interview, the probing questions were asked when it appeared necessary to obtain more information, remove the ambiguities regarding the given information, and obtain an in-depth understanding of the complex experiences of participants. For instance: What are your goals in life? What does life mean to you right now? How did the illness affect your attitude towards life? What do you do to improve the meaning of your life? Other questions were asked in terms of the participants’ answers. At the end of the interview, the following question was asked to answer any particular subject important to the participant that was not included in the interview: Do you have anything to add?
After obtaining a permit from the Research Council and Ethics Committee, Urmia University of Medical Science, before the interview, written and verbal information about the study was given, and written informed consent was attained from all participants. Their participation was voluntary, and they had the right to withdraw from the study at any stage. Interviews were conducted to discover and describe the dimensions of the meaning of life based on the lived experience of women with breast cancer. After obtaining the willingness to participate, an appropriate place and time were arranged for the interview. Data were collected via face-to-face interviews individually by the first author (26 interviews with 22 participants) and in a private room. All the interviews were audio-recorded and lasted between 27 to 76 min with an average of 45 min.
The conventional qualitative content analysis method was used to analyze the data based on the steps proposed in Graneheim & Lundman's approach [23]. The qualitative data analysis was carried out using MAXQDA software ver. 10) from the beginning of the study. Following Graneheim & Lundman's approach, after several listening times, the contents of all interviews were transcribed verbatim into Microsoft Word files. Afterward, the transcripts were compared to the audio data to ensure accuracy. To immerse themselves in the data, one of the researchers precisely reviewed the text of each interview several times. Subsequently, content analysis was started to serve as the background for extracting codes. At first, meaning units were identified; then, meaning units were summarized and designated with appropriate codes. One thousand eighty initial codes were extracted, then these initial codes were assessed based on similarities and differences, and 389 secondary codes were extracted. The first author reviewed the interviews, collected qualitative data, analyzed manifest and latent content, and extracted the codes. Then the researchers compared the codes within several sessions, discussed similarities and differences, and interpreted the latent content. After this stage, the codes were placed in subcategories and categories based on the similarities and differences. A category describes the content on a manifest level, with a low degree of interpretation and varying abstraction [24]. Finally, the research team increased the degree of abstraction and interpretation, and themes were extracted. A theme is a unifying ‘red thread’ running through several categories that bring meaning to the phenomenon under study and its various manifestations [24]. In this stage, the research team discussed subcategories and categories about the research aim and the concept under review to generate the themes. To ensure the trustworthiness or methodological soundness and adequacy, the following criteria proposed by Lincoln & Guba were employed: Credibility, transferability, dependability, and conformability [25]. Thus, the research was conducted by prolonged engagement with the data, peer check, member check, external audit, simultaneous analysis of the data, observing the maximum diversity in the participants, bracketing, constant supervision from the beginning up to the end of the research, elaborating on the manner of interviewing and data analysis, and precise and in-depth description of the research process.
Findings
The mean age of the participants was 48.18 years old, and their ages ranged from 30 to 79 years. Also, 82% of women were married (n=18), 4.5% were single (n=1), 9% were widow (n=2), and 4.5% were divorced (n=1). In terms of education, 18.2% of the women were illiterate (n=4), 13.6% had completed high school (n=3), 45.5% of the women had a diploma (n=10), and 22.7% of the women in our study were university graduates (n=5). As far as the occupation was concerned, 77.3% of the study participants were housewives (n=17), and 22.7% were employed (n=5).
Upon completion of the analysis, two themes were extracted; Categories in the “development in the process of life” included seven categories and 18 subcategories, and categories in ”the attempt to promote spiritual well-being” included the three categories and six subcategories (Table 1).
Table 1) Subcategories, categories, and themes indicating the meaning of life in women suffering from breast cancer
The theme of development in the process of life
Development in life was the main theme attained from the interviews. All the patients stated that cancer caused changes and developments in their lives, some positive and others negative, but for a short period. Categories and some stories of the participants in this regard were expressed as follows:
Feeling the change in life routine: The feeling of change in the life routine was one of the differentiating factors in the mental experiences of the interview participants. Among some women, this illness led to positive changes in their daily life, such as enjoying life despite the illness, gaining a better insight into people around them, feeling that they were reborn after the illness, and having a sense of empowerment. This illness led to negative changes in some women’s lives, such as anxiety and helplessness, temporary feeling of despair in life, hopelessness caused by the illness, and uncertainty regarding the complete recovery of the illness.
The participants stated that:
“I always fulfill my tasks despite the illness. I go to the park, parties, and weddings. I try to entertain myself. I always do my household chores” (P 13). “I try to enjoy every moment of my life” (P 5).
Achieving a better recognition of the life value: All women expressed that life became more valuable to them after being diagnosed with breast cancer, and they tried to do things that made them enjoy their life more than before. In this category, the following codes appeared: life appreciation, settling family disputes, maintaining joy in family, appreciating the health of their family and their own, understanding beauties of life, and having a better perspective on life.
The following were the statements made by some of the participants:
“Thanks to God, my husband treats me more nicely after my illness. He has changed a lot. Before my illness, he told me that he would divorce me; but after the illness, he never says anything inappropriate” (P 8). “My life became much
better after the illness. For instance, I felt more hopeful about how considerate my husband is and how much my husband and children care about me” (P 14).
Having life satisfaction despite the illness: Diagnosis and treatment of breast cancer could cause various problems for patients and their families and affect the quality of their lives in many aspects. Life satisfaction was manifested in some of the interviewees in the form of experiences such as lack of life satisfaction, becoming more content, and inability to change life and destiny. Some of them said:
“Life is like a road, it has ups and downs, but we have to endure it. I have no expectations of people. Everything is a lie, but death” (P 16). “Before my illness, I always thought about unimportant things, things like other people’s lives, and I wanted my life to be like theirs, but now, no way. I swear it is still like that; health is more important than anything. The important thing is that be happy with your own family” (P 8).
Hoping for and accepting that the illness will end: Hopefulness and achieving inner peace were among the priorities of patients with cancer, especially when witnessing the death of others. Hoping for and accepting that the illness would end were the differentiating factors in the mental experiences of women at the beginning of the illness when they might feel despair and are afraid of death. On the other hand, some women were strong right from the beginning of the illness. Some women expressed their experiences as follows:
“I was really strong, I knew it was nothing, and it will pass by. I knew that this illness was not dangerous and scary” (P 13). “I have a hopeful attitude. I look at life with hope, and the beauties that I have been overlooking now start to make sense to me. I try to enjoy every moment of my life” (P 5).
Trying to cope with the illness: Coping with cancer happens over time. In addition to the passage of time, other factors could affect this process, such as keeping patients’ spirits up, support of friends and family, and relationship with God. Some women participating in the interview described this process with concepts like getting used to the illness over time, being strong, and accepting the illness:
“I was shocked after being diagnosed with the illness. I cried a lot, and I thought that I would die. But after a while, I felt better, and I told myself that I have to be strong and try to fight this illness for the sake of my children” (P 18). “I did not know what to do, but God gives you the strength to fight it” (P 22).
Tolerating the pain and suffering of the illness: Breast cancer causes various problems for women suffering from it, such as chemotherapy, mastectomy, change in the mental self-image, and physical and mental problems which result in dysfunction both at home and at work. Tolerating the pain was easier for some women with a few problems, but some women had more severe problems. Some stories of the women’s experiences in this regard were expressed as follows:
“I still get nauseated when I see the medications. After each chemotherapy session, my body is painful, and I feel like my bones are breaking. I have lost my hair” (P 15). “I care too much about my body image, more than myself. After I lost my hair and removed my breast, I became really upset. It upsets you because it is a part of our femininity. If it was my stomach or intestine, it could not have the same impact” (P 21).
Worrying about the children’s future: All married women who participated in this study were worried about their children’s future, which is one of the major obsessions of married women. In a manner that they all wished to get better for the sake of their children and God to bestow them with a new life to see their children’s happiness. Some women expressed their experiences as follows:
“I am worried about my children, about taking care of them” (P 6). “I only think about my children, and I told myself how they are going to live after I’m dead? Can they live with a stepmother?! I am praying God to give me another life to see my children’s happiness” (P 17).
The theme of the attempt to promote spiritual well-being
Another theme attained from the interviews is the attempt to promote spiritual well-being. All participants in the study believed that their relationship with God was improved due to cancer, in a way that after being diagnosed with this illness, they felt closer to God. Categories of this theme and some stories of the women’s experiences in this regard are expressed as follows:
Personal belief: Personal belief creates an indescribable joy in you, a kind of joy that is not materialistic and results from the relationship with a transcendent power. Thanking God, surrendering self to God, believing that God is the Most Compassionate and the Healer of all, the feeling of spiritual peace, being satisfied with God’s will, and praying for self and others are the codes that appeared in this categories. Some of the experiences of these women about this are described as follows:
“I always thank God, and this spiritual relationship gives me inner peace, and I feel that I am closer to God more than anything” (P 5). “I started reading the Quran, I could not read it well, but I memorized some short Verses, this makes me feel peace on the inside” (P 4).
Spiritual contentment: Spiritual contentment is a process that is identified by appealing to God, feeling secure in God’s love, feeling closer to God, and is an important factor in human beings’ salvation. Spiritual contentment in some women manifested itself with experiences such as thinking of the illness as a Divine Test, believing in the reliance on God, stability in religious beliefs, rejoicing in carrying out good deeds, and the impact of true dreams in recovery. Some of the participants stated the following for this subject:
These are Divine Tests, and God is nagging you to see if you will leave Him or not? To see if I will forget Him? But I would never forget God, not even for a second” (P 1). “Reliance on God gave me the power to complete my treatment” (P 18).
Religious acts: All women who have breast cancer who participated in this study stated that after being diagnosed with the illness, they improved their relationship with God by carrying out religious acts. Women expressed their experiences with concepts such as improving the relationship with God to fight the illness, carrying out religious acts for recovery, offering oblations for recovery, improving the relationship with God after recovery, and believing that God will never forget them.
“After breast cancer diagnoses, I improved my relationship with God” (P 5). “God makes you sick because He wants to hear your voice. This illness made me think that God is teaching me like a mirror. I say to myself that God made me sick to hear my voice every day. I raise my hand, asleep and awake, and call God’s name and I tell God that you are the Savior, please save me, I say that O God you are my Healer” (P 1).
Discussion
In the present study, one of the experiences of women who have breast cancer regarding the meaning of life was the change in their life routine. In the study carried out by Bernard et al., it was found that the meaning of life is a strong preventive factor against psychological distresses at the end of life in the patients needing palliative care [17]. The meaning of life operates as a moderating factor against physical damage and hastens death wishes in patients who have advanced cancer [23]. Women who have breast cancer who possess a higher meaning in life and have the goals pertinent to the meaning show more resistance against cancer, and their immune systems operate better [26]. This association indicates that understanding the meaning of life could help patients suffering from cancer promote their quality of life, and cultural and social differences have no impact.
Achieving a better recognition of the value of life was one of the subjects that the participants had experienced from the meaning of life. Damasio et al. showed that the meaning of life has an important role in the positive performance of human beings; for instance, the meaning of life is linked to the quality of life, hope, optimism, self-efficacy, and self-confidence [11]. Nowadays, in palliative care, the meaning of life is one of the main factors in psychotherapeutic interventions. Even patients with limited life expectancy can still consider life as valuable [13]. This association of the results demonstrates that the meaning of life is a fundamental element in the psychological-emotional well-being of humans and could be pertinent to various dimensions of personality, mental and physical health, compatibility, and adaptation to stresses on a systematic basis.
Another category was the satisfaction of life despite the illness. Tork Moghadam indicated that confusion and diminution of the meaning in life demonstrate the decrease in the feeling that life is valuable and expresses the belief that life is a negative experience. In this case, there will be no encouragement to pursue the important goals, and people will be confused about themselves and their lives [19]. Diagnosis and treatment of cancer cause dysfunctions, including physical image, stress,
anxiety, hopelessness, weariness, fear of death, and incapability [27]. The association of results could be due to adaptation based on the meaning of life after being diagnosed with an incurable disease.
Hopefulness and accepting the ending of the illness were another common experience amongst the women. Halama & Dedova found that understanding the meaning of life could increase the tolerance threshold of a person, and having a meaning in life could result in welfare and life satisfaction [28]. This helps people who have more meaning perfectly confront life challenges and stress [29]. Therefore, the meaning in life could create positive feelings in people, which effectively confronts the feeling of lacking purpose in life and despair.
Trying to cope with the illness was an important category of this study; the role of spouse, family, and friends is of great importance. Sources of social support could play a determinant role in the adjustment process with the life crises [30]. The coordination and adaptation aspect of the meaning of life is made of positive thoughts and mental status, which creates a feeling of peace, security, and comfort in the mind [19]. Thus, finding meaning in life is one of the positive factors for helping patients cope with the severe conditions of the illness.
Tolerating the pain and suffering of the illness was among other women’s experiences. In the study carried out by Mozaffari et al. regarding children who have cancer, it was found that children experience more pain due to the nature of the illness [31]. Travelbee, in the “Middle-Range Theory of Spiritual Well-being in Illness,” argued that “a person’s attitude regarding illness and pain is a person’s attitude toward suffering ultimately determines how effectively he copes with illness” [18]. Enhancement of the meaning in life helps a person overcome conflicts and results in improving personal life satisfaction. Seemingly, this feature of meaning plays an important role in helping people overcome situations filled with conflict and tension.
Worrying about the children’s future is one of the most obvious categories of the study and amongst the common experiences of all women. In the study conducted by Vaziri et al., the results indicated that the increase in the awareness of mothers who have cancer regarding the necessity of the mother-child relationship could create a more positive perspective of mothers to the mother-child relationship [32]. A mixed-method study was conducted by Baltisberger et al. in the United States. This study showed that “bent but not broken” was a powerful metaphor that mothers during chemotherapy for breast cancer used for their duties towards the children [33]. Adams and Dell‘s study indicated that women who choose mastectomy are most worried about their children as a mother [34]. The association of these results demonstrates that when facing a personal problem, all mothers, from all cultures and societies, worry about playing their different roles, such as a maternal role for their children, and try to play this role in the best way possible.
The next category is Personal belief. In the study carried out by Mozaffari, some participants stated that they always had faith in God and deeply believed that God determined life to be this way and living in this world should be by God’s will [31]. Karekla & Constantinou argued that in adults who have cancer, believing in God and religious beliefs, in general, is an important aspect in coping with cancer [35]. The association of the results indicates that in the experience of living with cancer, personal belief and believing in God is one of the notable and important aspects of a healthy life.
Spiritual contentment is amongst another experience of women about the meaning of life. Spiritual beliefs are embodied in every aspect of a person’s health, direct daily habits and are the source of support, power, and recovery [36]. “Life, as a groundwork of Divine Tests” is one of the main themes of the qualitative research carried out by Mozaffari et al. and shows the existent of a kind of deep belief in God in the children who have cancer [31]. Joulaee et al. carried out a study concerning the lived experience with breast cancer. The findings of this study showed that patients felt closer to God more than ever, and religious beliefs helped them obey God and cope better with their conditions illness [37]. Therefore, believing in God and relying on Him serves as an important and powerful response for the meaning of life. It could be considered a positive mechanism for adaptation and coping with the illness.
Another category is carrying out religious acts. The personal relationship with God and the Higher Beings is one of the aspects of spiritual well-being [38]. Understanding the goal and the meaning of life is the pivotal part of spirituality in the Holistic Nursing Theory, which demonstrates the wholeness of individuals and their relationship with the Higher Power [39]. Halligan, in his study, demonstrated that relationship with God serves as the spiritual need in Christian American patients with cancer [40]. This association of results indicates that Theology is the basis of all religions, and cultural differences have no impact. Human beings in any religion rely on God in any severe condition and appeal for God’s help to overcome their problems.
One of the limitations of our study was the unwillingness of some women to participate in this study due to their reluctance to recall the bad memories from the past. The findings of this study could be beneficial as a conceptual basis for explaining the concepts in other studies and/or designing spiritual intervention programs and even carrying out palliative care in oncology wards. Because this study was carried out in one region of a country and it could not represent all women who have cancer and taking into account that very few studies have been carried out concerning the meaning of life in women with cancer, thus, it is suggested that to determine other aspects of spiritual life in these people, other qualitative and quantitative studies should be carried out about these women and other patients who have cancer to improve the quality of life and find the meaning of life. Moreover, educational courses should be held, and the necessary support should be provided.
Conclusion
The meaning of life in women with breast cancer is a multidimensional concept. The development in the process of life and the attempt to promote spiritual well-being are the most predominant experiences. Understanding the meaning of life can promote their spiritual well-being and quality of life. Considering that women carry out important roles in the family and even in society, the health system should take necessary measures to improve the meaning of life in these patients, support them and build a proper relationship with these patients.
Acknowledgments: The authors would like to express their deepest gratitude to the Vice-Chancellor for Research of Urmia University of Medical Sciences, all participants of the study, and estimable colleagues, especially in Omid and Imam Khomeini Hospital of Urmia and Shahid Madani Hospital of Khoy.
Ethical Permissions: The study was approved by the Research Council and Ethics Committee of the Urmia University of Medical Science [IR.UMSU.REC.1397.277].
Conflicts of Interests: This research is part of a Ph.D. thesis, and all authors declare that they have no competing interests. Also, the funding body had no role in the study’s design, data collection, analysis, interpretation of data, or writing the manuscript.
Authors’ Contribution: Mokhtari L (First Author), Introduction Writer/Main Researcher/Discussion Writer (50%); Feizi A (Second Author), Statistical Analyst (20%); Khalkhali HR (Third Author), Assistant Researcher (10%); Khorami Markani A (Fourth Author): Methodologist (20%)
Funding/Support: We did not receive any grant from funding agencies in the commercial or not-for-profit sectors. This project was supported by the Research Deputy of Urmia University of Medical Sciences.