{"paper_id":"6421bc94-de69-467d-afcd-b839ad4f866d","body_text":"Goudarzi et al. BMC Women’s Health           (2022) 22:40  \nhttps://doi.org/10.1186/s12905-022-01615-2\nRESEARCH\nWomen’s interdependence \nafter hysterectomy: a qualitative study based \non Roy adaptation model\nFatemeh Goudarzi1,2, Talat Khadivzadeh3,4, Abbas Ebadi5,6 and Raheleh Babazadeh3,4* \nAbstract \nBackground: Hysterectomy is a difficult process that some women encounter that can affect their interdepend-\nence, but its impact on women’s Interdependence has received less attention. Therefore, this study aimed to explain \nwomen’s Interdependence after hysterectomy.\nMethods: This qualitative study was performed using a directed content analysis approach in Mashhad (Iran). Thirty \nwomen with a history of hysterectomy were included in the study by purposive sampling method. Data were col-\nlected from August 2018 to November 2019 using semi-structured interviews based on the interdependence mod of \nthe Roy adaptation model until data saturation. Data analysis was performed using MAXQDA software and the deduc-\ntive approach of Elo and Kingas (J Adv Nurs 62(1):107–115, 2008. https:// doi. org/ 10. 1111/j. 1365- 2648. 2007. 04569.x).\nResults: Data analysis led to the production of 537 initial codes from participants’ experiences. By merging and \ncategorizing them, the theme of “increasing interdependence” emerged, which consists of 2 categories: “Evolu-\ntion independence and interaction with important people in life” and “Reinforced support system” , that include six \nsubcategories.\nConclusion: After hysterectomy, women not only feel a strong need for support from family members, especially \ntheir husbands, they are also seeking support from health care providers and their colleagues. Before the hysterec-\ntomy, it is recommended that family members be consulted to ensure the emotional support and care of women \nafter the hysterectomy. It can help the adaptation to hysterectomy.\nKeywords: Hysterectomy, Interdependence, Qualitative Study, Roy adaptation model\n© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which \npermits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the \noriginal author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or \nother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line \nto the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory \nregulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this \nlicence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco \nmmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.\nBackground\nHysterectomy is one of the most frequent gynecological \nsurgeries. Prevalence of hysterectomy in countries such \nas the United States 26.2%, Australia 22 percent, Ireland \n22.2 percent, Taiwan 8.8 percent, and Singapore 7.5 per -\ncent [1]. Culturally, the relationship between the uterus \nand the sense of femininity and sexuality, in addition \nto its role in fertility, has made the uterus an important \norgan for women [2]. Hysterectomy can be a difficult \nprocess for women. Since the uterus is a very important \npart of the body, its removal has physical and emotional \nconsequences and it may lead to severe psychological \nreactions in women [3–5]. A psychological complica -\ntion of hysterectomy includes depression [6], Anxiety [7], \nand stress [8]. The risk of pelvic floor prolapse, urinary \nincontinence, and sexual dysfunction are some of the \nphysical complications associated with hysterectomy [9]. \nIn addition to concerns about the surgery itself, hysterec-\ntomy also leads women to worry about the postoperative \nexperience. The reason for this concern is the importance \nOpen Access\n*Correspondence:  BabazadehR@mums.ac.ir\n3 Nursing and Midwifery Care Research Center, Mashhad University \nof Medical Sciences, Mashhad, Iran\nFull list of author information is available at the end of the article\n\nPage 2 of 11Goudarzi et al. BMC Women’s Health           (2022) 22:40 \nof the uterus for women. Silva et al. [10] stated that the \nuterus is important to the performance of women’s social \nroles. The loss of an organ related to femininity such as \nthe uterus is associated with decreased adaptation [11].\nHysterectomy can have a significant impact on a wom -\nan’s life and social interactions [12, 13]. Social relation -\nships include interactions between different people and \nhow they affect each other, and include personal rela -\ntionships, social support, and sexual activity [14]. Social \ninteractions are characterized by distinct forms of inter -\ndependence [15]. Social interactions and social relations \nhave been identified as important predictors of health \nand well-being. They are two aspects of social relations \n[11]. Researchers believe that social relationships can \naffect health and Social support promotes mental and \nphysical health among patients [11, 16–19]. Different \naspects of women’s relationships with family, friends, \nco-workers, and health care providers affect their cop -\ning strategies [20]. Wu et al. found that receiving support \nfrom family and friends affected and strengthened wom -\nen’s confidence in accepting hysterectomy. These indi -\nviduals provided emotional and informational support to \nthe patient [21].\nRoy Adaptation Model (RAM) is one of the nursing \nmodels that is commonly used in nursing research. In \nthe RAM, human beings are considered as a system of \nadaptation that interacts with the environment. Accord -\ning to the RAM, the result of the mechanisms used \nby individuals to cope with stimuli is reflected in their \nbehaviors. Behavior in RAM refers to the internal and \nexternal actions and reactions of individuals to stimuli \nand is defined as a set of feelings, thoughts, and behav -\niors of individuals. In the RAM, behaviors are described \nas adaptive or non-adaptive behaviors. Roy defined four \nmodes of adaptation, including physiological, self-con -\ncept, role function, and interdependence. The physiologic \nmode is focused on the structures of the body and how \nthey function. The self-concept mode includes individu -\nals’ feelings and thoughts about themselves. The focus of \nthis mode is on the psychological and spiritual aspects \nof the individual. Role function mode includes behaviors \nrelated to the individual’s roles in the family or commu -\nnity. It also refers to the expectations that must be met \nby the individual in each of these roles. The interdepend -\nence mode refers to the social and relational integrity of \nthe individual and was also focused on giving and receiv -\ning social support [22]. In accordance with the purpose \nof this study, the mode of interdependence has been con-\nsidered for this study. Interdependence is the process by \nwhich people interact with each other and it focuses on \nthe impact of the consequences of each person’s behavior \non themselves and others [23]. Interdependence can pro -\nvide fundamental insight into an individual’s adaptation \nto the social environment [15]. In different diseases, \ninterdependence has been studied based on the RAM. \nIn a phenomenological study based on RAM, the experi -\nences of patients, their families and nurses working in the \nintensive care unit during the critical illness period were \nexamined and the result showed that there is an interde -\npendence between all of them [24]. Also, the experience \nof Turkish pregnant women with nausea and vomiting \nduring pregnancy was assessed using RAM and the par -\nticipants’ experience showed that they were dissatisfied \nwith their relationships with important people in their \nlives and with supportive resources and disruption of \ninteraction with their social environment [25]. In another \nstudy, the experience of patients who underwent bariatric \nsurgery under the guidance of RAM was examined and \nthe results showed that body image surgery improves \nsocial life, personal relationships and performance of \nparticipants [26]. The adaptation experiences of Turkish \npatients who underwent liver transplant surgery were \nevaluated according to the RAM. The results showed \nthat the relationship between participants ’families and \npatients’ interactions with others improved [27]. There \nwasn’t found a qualitative study that examined the field of \nwomen’s interdependence after hysterectomy.\nThe effects of removal of the uterus as an organ that is \nclosely related to the definition of the role of women in \nsociety are often overlooked. In medical treatments, the \nfocus is on physical recovery and providing care, so the \nissue of the being-woman, reduced to the secondary plan. \nGiven that women are almost half of the community pop-\nulation, so they should be an important part of society to \ncodify to health policy [10]. Understanding the impact of \nhysterectomy on women’s social relationships and inter -\ndependence enables health care providers to help women \nto experience the adaptation process with less difficulty. \nShanti et al. [28] found that there is a significant relation-\nship between the family support and adaptation process \nand the quality of life of women who underwent a hyster-\nectomy. Given that there are differences between cultures \nin the experience of relationships, qualitative studies \ncan provide an in-depth insight into the experiences of \nwomen perspective. Therefore, this study aimed to dis -\ncover women’s experiences of interdependency adapta -\ntion after hysterectomy with a qualitative approach using \nthe RAM.\nMaterials and methods\nThis study was conducted by using a qualitative approach \nand a deductive content analysis method between June \n2018 to October 2019.The directed content analysis \napproach can be used when there is a previous theory or \nresearch on a phenomenon but it is incomplete or needs \nfurther explanation. The purpose of this approach is to \n\nPage 3 of 11\nGoudarzi et al. BMC Women’s Health           (2022) 22:40 \n \nvalidate or expand a theoretical framework, concept, or \ntheory. In this approach, the existing theory or research \nwhich guides the research is helpful in designing the \nresearch question and can also guide the determination \nof the initial coding scheme or relationships between \ncodes [29]. The interdependence mode of The RAM was \nused as a framework for exploring the experience of the \nhysterectomized women’s Socio- Emotional Interde -\npendence. In a directed content analysis approach, the \nclassification of the key concepts from the initial codes \nis determined based on a theory or concept. The open-\nended questions used to collect data were based on refer -\nence categories based on RAM [29].\nThis study was performed in two referral centers for \nhysterectomy affiliated to Mashhad University of Medi -\ncal Sciences Iran. The study population consisted of all \nthe women who have undergone hysterectomy. Inclusion \ncriteria were: the ability to speak Persian, having a his -\ntory of hysterectomy surgery during the 6 months to past \n10  years, interest in participating in the study, no men -\ntal disorder or dementia, no use of sedatives and drugs. \nExclusion criteria were unwillingness to continue par -\nticipation in the study. Purposive sampling was used with \nthe highest Variety in age, educational level, occupation, \ncause of hysterectomy, time after hysterectomy and Men-\nopausal status before hysterectomy, number of children, \nmarital status.\nThe participants were identified based on the hos -\npitalization information file. Using a phone call, while \nexplaining the purpose of the study, they were invited \nto participate in the study. Data were collected using \nsemi-structured in-depth interviews. In the interviews, \nopen-ended questions were asked based on the interde -\npendence mode of the RAM: “Describe your relation -\nship with others since the time of hysterectomy.\" To get \ndeeper information, questions such as “Would you please \nexplain more?” and “would you please make your point \nclearer?” were asked. The interviews were held based on \nthe convenience of the participants in a quiet place. Even-\ntually, the data was saturated after the participation of 30 \npartisans. The interviews lasted between 30 and 96 min \n(average 60 min). With the conscious written consent of \nthe participant, the interviews were recorded and tran -\nscribed verbatim immediately after each interview.\nData analysis was performed using the deductive con -\ntent analysis of Elo and Kingas [30]. With MAXQDA \nsoftware (version 10, VERBI Software, Berlin, Ger -\nmany). In this approach, the researcher begins coding \nand categorization by identifying key concepts or vari -\nables using existing theory or previous research [29]. In \nthis study, the main concepts were identified based on \nthe interdependence mode and the coding and catego -\nrization process began. At first, the transcribed version \nof the interviews was prepared by the first author and \nthen read several times to get a general understanding \nof their content. The text of all interviews was selected \nas the meaning unit. An unconstrained matrix of analy -\nsis was developed according to the interdependence \nmode of the RAM. While reading the text, Sentences \nor paragraphs were reviewed and Phrases, sentences, \nand paragraphs related to the Purpose of the study \nwere identified and coded. The codes were placed in \nthe matrix of analysis based on their similarities to the \nconcepts of the interdependence mode RAM matrix, \nand then the codes were grouped into subcategories \naccording to similarities. Larger categories emerged \nfrom grouping subcategories based on similarities and \ndifferences of concepts. This process continued until \nthe main theme emerged. The data analysis process was \ndiscussed during several joint meetings of the research \nteam to reach a consensus.\nFor the credibility of the data, enough time was spent \ncollecting and analyzing the data. The researcher was \nlong time involved in the field of research and data. The \nresearch team reached a consensus regarding data anal -\nysis. The members of the research team were experts \nin qualitative studies and had experience working in \nmedical and educational centers in the field of gynecol -\nogy and midwifery. The accuracy of the interview text \nwas confirmed by some participants after transcrip -\ntion. For the dependability of the data, the data analysis \nprocess was verified by two external evaluators familiar \nwith qualitative study and gynecological diseases. To \nensure confirmability, the processes of study and details \nof data analysis were recorded and reported. The quo -\ntations of the participants were presented according to \ntheir statements. For transferability, the demographic \ncharacteristics of the participants and the field of study \nwere described in detail. With the entry of participants \nwith different demographic characteristics to study and \nreporting the study process carefully, it is possible for \nthe reader to decide on the use of the results.\nResults\nIn this study, Key concepts and categorization of initial \ncodes were conducted and reported based on the pre -\ndicted categorization in the interdependence mode of \nRAM. The demographic characteristics of the partici -\npants have been summarized in Table  1. Data analysis \nled to the product of 537 initial codes from the partici -\npants’ experiences, by merging the similar codes, 124 \ncodes were obtained. Finally, the theme of increasing \ninterdependence was emerged, which includes two cat -\negories and six sub-categories (Table 2 ).\n\nPage 4 of 11Goudarzi et al. BMC Women’s Health           (2022) 22:40 \nEvolution in dependence and interaction with important \npeople in life\nMost participants in this study reported experiencing a \nsense of loss after a hysterectomy, which affected their \nemotional state and emotional relationships. In the pre -\nsent study, participants experienced a change in their \nrelationships with people who were important in their \nlives after hysterectomy. These changes ranged from \nincreasing to decreasing relationships. This category \nconsists of three subcategories.\nEvolution in spiritual relation\nMost participants experienced fear and unreliability after \na hysterectomy. Most participants reported that they \nsought refuge in a source of power to overcome this fear \nand uncertainty. They often improved their spiritual rela-\ntionship with God as absolute power. A participant stated \nthat:\n“My communication with God has been increased. I \nfeel as if he was on my side during this difficult time. \nI talk to him more. I relied on God. ” (P16)\nTable 1 Sociodemographic characteristics of the participants\nChild number Menopause status Marital status Hysterectomy \nduration \n(year)\nHysterectomy reason Job Education level Age Participant \ncode\n2 Non-menopausal Married 1 Fibroma Housewife High school 39 P1\n2 Non-menopausal Married 3 Fibroma Retired University 54 P2\n2 Non-menopausal Married 10 CIN2 Retired University 57 P3\n3 Non-menopausal Married 1 Bleeding Housewife Junior School 44 P4\n2 Non-menopausal Married 3 Irregular bleeding Teacher University 43 P5\n1 Non-menopausal Divorced 4 Atypical endometrial \nhyperplasia\nNurse University 36 P6\n3 Non-menopausal Married 2 Placenta accrete Housewife High school 35 P7\n0 Menopause Married 1 Atypical endometrial \nhyperplasia\nRetired University 54 P8\n1 Non-menopausal divorced 4 Cervical cancer Secretary University 46 P9\n4 Non-menopausal Married 4 Fibroma Housewife Junior School 46 P10\n2 Non-menopausal Married 4 Atypical endometrial \nhyperplasia\nHousewife Elementary 40 P11\n4 Non-menopausal Married 3 Endometrial cancer Housewife Junior School 48 P12\n3 Non-menopausal Married 1 Fibroma Teacher University 40 P13\n3 Non-menopausal Married 3 Fibroma Housewife Junior School 48 P14\n3 Non-menopausal Married 2 Malignant\nFibroma\nHousewife High school 40 P15\n3 Non-menopausal Married 2 Ovarian cancer Housewife Elementary 43 P16\n2 Non-menopausal Married 8 Atypical endometrial \nhyperplasia\nRetired University 53 P17\n3 Non-menopausal Married 5 Placenta accrete Housewife Junior School 42 P18\n0 Non-menopausal Single 1 Fibroma Employee High school 37 P19\n2 Non-menopausal Married 2 Placenta accrete Housewife High school 37 P20\n2 Non-menopausal Married 3 Postpartum hemorrhage Housewife High school 33 P21\n2 Non-menopausal Married 1 Fibroma Housewife High school 45 P22\n3 Menopause Widow 1 CINIII Housewife Elementary 52 P23\n2 Non-menopausal Married 3 Fibroma Housewife Elementary 47 P24\n5 Non-menopausal Married 2 Fibroma Housewife Elementary 51 P25\n3 Non-menopausal Widow 1 Fibroma Housewife Elementary 45 P26\n1 Non-menopausal Married 2 Ovarian cancer Housewife University 40 P27\n3 Non-menopausal Married 3 Postpartum hemorrhage Housewife Elementary 27 P28\n10 Menopause Married 8 postmenopausal Bleeding Housewife Elementary 68 P29\n1 Menopause Married 9 Uterine prolapse Housewife Elementary 60 P30\n\nPage 5 of 11\nGoudarzi et al. BMC Women’s Health           (2022) 22:40 \n \nTable 2 Main categories and subcategories of interdependence after hysterectomy\nCod Sub-category Category Theme\nFading relationship with God Evolution in spiritual relation Evolution in dependence and inter-\naction with important people in life\nIncreasing \ninterde-\npendenceReducing communication with God\nMaintaining the relationship with God\nImproving communication with God\nIncreasing dependence on offspring Fluctuation in emotional dependency on \noffspringmore intimacy with offspring\nIncreasing relationship with offspring\nIncreasing interest in offspring\nbecoming more kind to offspring\nExpressing more love to offspring\nTaking Care of Kids with more sensitivity\nHiding grief due to hysterectomy from offspring\nTrying to reduce offspring dependence\nReducing attachment to the offspring\nNo change in dependency to the offspring\nmore intimacy to the spouse Change in emotional relationship from the \nspouseImproving emotional attachment with spouse\naugmenting love and affection to the spouse\nThe tendency to spend more time with spouse\nNeed to be with the spouse\nbeing relaxed in the presence of the spouse\nThe desire to have a close relationship with a \nspouse\nshowing appreciation to the husband with Paying \nmore attention to his support\nStrengthening friendship with husband\nSpend more time with spouse\nImproving emotional relationship with the spouse\nCompassion for the spouse due to limited sexual \nActivity\nImpaired emotional relationship with the spouse \nNot talking about self-issues with the spouse\nNot accompanying with spouse\nFeeling apathy to the spouse\nTendency for independence from the spouse\nReceiving consolation from the spouse The family as a refuge to receive emotional sup-\nport and care\nReinforced support system\nthe companionship of the spouse in a lonely time\nreceiving spouse financial support\nreceiving spouse care\nreceiving care from family members\nreceiving care from relatives\nTrusting to receive family support in difficulty\nTaking refuge to the family to escape anxiety\nTaking refuge to the family to escape anxiety\nReceiving Consolation from the family\nPrioritizing attending family gatherings rather than \nattending other gatherings\n\nPage 6 of 11Goudarzi et al. BMC Women’s Health           (2022) 22:40 \nA small number of participants decreased their relation -\nship with God and complained to God about the loss of \ntheir uterus. One of the participants said:\n“I had so many problems after the hysterectomy. \nI complained to God. I was ungrateful… I lost my \nrelationship with God… ” (P21)\nFluctuation in emotional dependency on offspring\nMost participants reported losing their fertility after \nuterine surgery. Therefore, they became emotionally \ndependent on their children. They described knowing \nthat current children are the only possible children for \nthem to increase their dependence, intimacy with their \nchildren, and described their close relationship with their \nchildren. One of the participants said:\n“I missed the opportunity to have children so my \ndependence on my children increased greatly. I had \nonly these two children. ” (P22)\nA small group of participants described their negative \npsychological experiences after hysterectomy and said \nthat these experiences reduced their dependence on their \nchildren. Participants described decreased attachment, \nefforts to reduce dependency, and reduced intimacy with \nchildren. A participant said:\n“I have blame others, even my children in my hys -\nterectomy. If I had not become pregnant, I would \nhave remained a healthy and complete person. I am \nno longer as attached to my children as I used to be. ” \n(P28)\nFor many participants in this study, hysterectomy was \nthe main stimulus for dependence on children So they \nwere more committed to caring for their children. Tak -\ning every opportunity to express love and affection for \nher children was a behavior that these women displayed \ndue to the loss of their fertility. They said they were more \nsensitive to their children’s future and health. One par -\nticipant said:\n“I can no longer have a child, so I have to take more \ncare of my children so that nothing happens to \nthem… ” (P1)\nChange in emotional relationship from the spouse\nMost of the participants stated that hysterectomy \naffected their emotional relationship with their spouses. \nTable 2 (continued)\nCod Sub-category Category Theme\nReceiving encouraging and supporting  \ncolleagues to pursue treatment\nSupportive friends and peers\nIncreased cooperation of colleagues in perform-\ning my duties due to physical disability\nIncreasing the emotional support received from \nothers\nIncreasing communication with hysterectomies \nwomen\nReceiving guidance from hysterectomies women\nIncreasing emotional relationship with supportive \nfriends\nTaking refuge in friends\nSpending more time with friends\nReducing contact with friends to preventing \nstigma\nCutting off relationship with some of friend\nThe disappointment of friends due to lack of \nsupport\nReceiving support from the physician Supportive health providers\nReceiving emotional support and respect from \nnurse\nUnderstanding affectionate communication of \nhospital staff\n\nPage 7 of 11\nGoudarzi et al. BMC Women’s Health           (2022) 22:40 \n \nMost of the participants described the improvement in \ntheir emotional relationship with their spouses because \nof the support that they received from their spouses after \nthe hysterectomy. Some said that being with their spouse \ncan calm them down. Others indicated that the presence \nof their spouse during the illness and treatment enhanced \ntheir interest. A group also described the need to be with \ntheir spouse. Some also wanted to have a more intimate \nrelationship with their spouse. One participant said:\n“After the hysterectomy, I had a better relationship \nwith my husband than before. I have peace by his \nside. We spend more time together. ” (P14)\nSome of participant stated that the loss of the uterus \nmade women feel void and deficient. They were con -\ncerned about their spouses’ reaction to their condi -\ntion. This concern led some of these women to describe \nproblems in their relationship with their husbands. They \nwere reluctant to talk about their personal issues with \ntheir spouses. They did not accompany their spouses for \nwork and leisure, they felt disinterested in their spouses, \nand some said they wanted to be independent of their \nspouses. One participant said:\n“After the hysterectomy, I try to distance myself from \nhim… I’m worried about what he thinks of me. I will \nnot talk to him about myself anymore. ” (p13)\nSome women did not receive enough support from their \nhusbands after hysterectomy, and as a result, they felt \nlonely and abandoned. Lack of support from the spouse \nharmed women’s emotional relationships with their hus-\nbands and caused an emotional breakdown between \nthem. One participant said:\n“If I had not been emotionally attached to my hus -\nband, his absence after hysterectomy would not have \nupset me. I’m disappointed in him. I cannot commu-\nnicate with him easily. ” (P7)\nSome participants owed themselves to their spouse’s \nloving behavior. They tried to compensate for the lov -\ning behavior of their wives. They strengthened their \nemotional relationship with their spouse. They tried to \nimprove their emotional relationship with their spouse. \nThey stated that the relationship between them has \nbecome friendlier than in the past. One of the partici -\npants said:\n“I am owing to my husband’s behavior. He was com-\nmitted to me during the difficult surgical condi -\ntions. Now I appreciate my husband more. I like him \nmore. ” (P15)\nReinforced support system\nIn this study, a support system including family, col -\nleagues, friends, and health care providers were described \nthat supported participants in the areas of physical, care, \nemotional, and informational support. This category con-\nsists of three sub-categories.\nThe family as a refuge to receive emotional support and care\nFor most participants, the family served as a refuge for \nemotional support and care. Many participants said that \ntheir family members comforted them. Some women \nstated that after hysterectomy, they welcomed their \nhusbands’ supportive-caring behaviors. Some partici -\npants also described the spouses’ financial support. A \ngroup of women described receiving family care, includ -\ning their husbands, parents, sisters, and even relatives. \nThey stated that when they felt lonely, they found their \nspouse by their side. Some participants stated that they \nsought refuge with their families when they experienced \ncomplications such as anxiety and stress after a hyster -\nectomy. Being with family members calms them down. \nThey trusted to receive support from their family in times \nof trouble. Although they were reluctant to attend pub -\nlic gatherings, they preferred to attend family gatherings. \nOne participant said:\n“I have been stressed and anxious since the hysterec-\ntomy. So I take refuge in my family (father, mother, \nand sisters). I am at peace with them. They comfort \nme. ” (P28)\nSupportive friends and peers\nMany women after hysterectomy describe physical limi -\ntations, especially in the workplace and in life. They \nstated that after facing these limitations, they enjoyed the \nsupport, encouragement, and help of colleagues, friends, \nand others to overcome these limitations. Some partici -\npants explained that because talking to men about female \ngenitals was taboo, they tried hard to hide the type of \noperation in their work environment. They stated that \nwhen co-workers realized the difficulty of moving and \ndoing work, they helped a lot in doing hard work without \nasking why. Also, some participants described their expe-\nrience of being encouraged by colleagues and workplace \nofficials to pursue treatment. One participant said:\n“After the hysterectomy, I couldn’t do hard work. \nSince most of my colleagues were men, I could not \ntalk to them about my surgery. But they helped me. \nThey were careful that I do not get pressured while \ndoing work. ” (P6)\nMany participants were concerned about limited infor -\nmation on hysterectomy and its complications. In this \n\nPage 8 of 11Goudarzi et al. BMC Women’s Health           (2022) 22:40 \nregard, they communicated with women who had previ -\nously had a hysterectomy. They became a source of infor-\nmation support for the participants. One participant said:\n“I faced a lot of problems after my hysterectomy. I \nmet several hysterectomized women. They guided \nme. I still get help from them. ” (P8)\nSome participants introduced their friends as a source \nof support. They said their friends gave them emotional \nsupport and care after the hysterectomy. A group of \nwomen stated that they took refuge in their friends and \nspent more time with them. One participant said:\n“I hid my Surgery from my family, only my friend \ncame with me. She took care of me. ” (P13)\nSupportive health providers\nA group of health care providers and several physi -\ncians provided emotional support to participants dur -\ning treatment and follow-up visits. During care for \npost-hysterectomy, receiving clinical care with expres -\nsions of affection from health personnel, including pain \nrelief, nutritional assistance, and mobility, were some of \nthe items described by participants. Some participants \nexperienced severe pain. They said they had no hope of \nrecovery at the time, but the information and guidance \nprovided by the nurses were promising and alleviated \ntheir suffering. Some of the participants experienced \nfear combined with the feeling of loneliness in the recov -\nery room. The fear and do not being aware of what had \nhappened caused a feeling of insecurity in some partici -\npants in the early hours after the operation. The affection \nbehavior of the doctor and the nurse made them feel safe. \nA group of participants described receiving emotional \nsupport and encouragement from health personnel. They \nstated that the support was beyond the physiological care \nexpected of a physician or nurse during an illness. Some \nsaid that the kind behavior of the doctor and the health \nstaff at the hospital motivated them to cope with the situ-\nation. One participant said:\n“After hysterectomy, I was hospitalized in the ICU. \nThat atmosphere was scary for me. But the ICU staff \nwas excellent. I will not forget the energy I took from \nthem in those days. ” (P7)\nDiscussion\nThis study explored the women’s experiences of interde-\npendency adaptation after hysterectomy under the guid -\nance of the interdependence mode of the RAM. In the \nRoy Adaptation Model, two specific close relationships \nare explained in the mode of interdependence. The first \nexplained relationship is the relationship with the impor -\ntant people who are very important to the person’s life. \nThe second is the relationship with support systems that \npoint to those who help meet the needs of interdepend -\nence [22].\nThe results of this study showed that after hysterec -\ntomy, the interdependence between women and fam -\nily members, including spouse, parents and children,, as \nwell as the support system including family members, \ncolleagues, friends, peers, medical staff increased. Par -\nticipants experienced changes in their relationships with \npeople who were important in their lives due to loneli -\nness, changes in self-concept, loss of fertility. These \nchanges ranged from increasing relationships to break -\ning up of relationships. Most of the changes described \nwere related to changes in relationships with spouses and \nchildren. After gynecological surgeries, women found \nthemselves different from others, and this difference \nwas the result of a person’s interaction with herself and \nothers [31]. The emotional breaking-up between cou -\nples due to decreased sexual desire and loss of fertility is \none of the most important concerns of women who have \nundergone surgeries that cause menopause [32]. After a \nhysterectomy, women feel lonely and isolated. Feelings \nof shame, regret, anxiety, depression, and social isola -\ntion are some of the problems that affect women’s social \nand family relationships after hysterectomy. Concerns \nabout the husband’s negative reactions to a hysterec -\ntomy caused women to distance themselves from their \nhusbands to solve the problem, run away from the rela -\ntionship with the husband, and sometimes allow the hus -\nband to remarry [33]. On the other hand, the results of \nthis study showed an improvement in the relationship of \nmany participants with their spouses. After evaluating \ntheir lives after a hysterectomy, women achieved posi -\ntive aspects such as a chance to live again and enjoy with \nfamily especially spouses [34]. In this study, Most of the \nwomen improved their spiritual relationship after hyster-\nectomy. They increased their spiritual relationship. They \nattended Quran recitation sessions and used prayer to \nbring peace. Spiritual communication, such as praying, \nreciting the Holy Quran, listening to music, walking, and \nsports (yoga), is one of the adaptive strategies used by \npeople after a hysterectomy [4].\nLoss of fertility after a hysterectomy increased women’s \nemotional dependence on their children. Therefore, they \nbecame more sensitive to the care of their children. In \nsome studies, women described fertility loss after hyster -\nectomy as a loss of hopes and dreams [4]. In particular, \nwomen who underwent hysterectomy and experienced \nsecondary infertility after hysterectomy faced whit a \nvariety of issues, including defects in their integrity as a \nperfect woman which is often overlooked by health care \n\nPage 9 of 11\nGoudarzi et al. BMC Women’s Health           (2022) 22:40 \n \nproviders[35]. Women with secondary infertility consider \ntheir current child to be a blessing from God. The limited \nnumber of children is stressful for these mothers. She \nand her family had high hopes for their existing child/\nchildren, leading to high levels of fear and stress [36].\nIn this study, participants described the association \nwith an enhanced support system involving colleagues, \nfriends, and the caregiver team, which was helpful for \nbetter adaptation to hysterectomy. However, in the lit -\nerature review, no study was found that examined the \nrole of the support system in adapting to hysterectomy. \nThe need for compassionate behavior in care sectors and \nthe organization of support groups have been identified \nfor hysterectomies women in studies [32, 37]. Women’s \ninteraction with the community around them, receiving \nstimulus support, and encouraging support from family \nand friends are important strategies for overcoming the \nbarriers and limitations of illness [38]. One source of sup-\nport for women after a hysterectomy is their colleagues. \nThe employed women who underwent hysterectomy \nwere less anxious. One of the reasons was their involve -\nment in society. Therefore, access to social support could \nbe a strategy for adapting to hysterectomy [39].\nMost participants supported by their family members. \nThe support that they received included care, expres -\nsions of love, respect, and emotional support that helped \nwomen recover from the physical, psychological, and \nemotional consequences of the hysterectomy during their \nrecovery period. This support gave participants a sense \nof calm and confidence. They also expressed mutual \nlove, respect, and care for family members, friends, and \nrelatives. These findings were confirmed by other studies \n[11, 37, 38]. In these studies, social support dimensions \nidentified as emotional relationship, affectionate, positive \nsocial interaction, help, and care. After losing an organ \nof the body, women can better adapt to their social envi -\nronment through the support, encouragement, and help \nof family, friends, or even a support group. In fact, these \nsupportive behaviors are a way to overcome the obstacles \nand limitations of living with the loss of an organ [31]. \nAccording to the findings of this study, Husbands, as the \nmost important source of support, play a significant role \nin women’s adaptation to the hysterectomy. The provi -\nsion of support and care of a husband and the accom -\npaniment of a woman with a sexual partner represent a \nstrong relationship that can not only reduce the stress of \nan important gynecological surgery such as a hysterec -\ntomy but also lead to closer relationships [40]. According \nto the findings of this study, women’s interdependence \nafter hysterectomy with family members and relatives is \nvery important in adapting women to the hysterectomy. \nHusbands, as the most important source of emotional \nand care support, also play a significant role in women’s \nadaptation to the Psychological aspects of hysterectomy. \nIn Iranian society, especially at the time of encountering \nimportant events such as hysterectomy, family members \nplay an important role in the processes of decision-mak -\ning and care for the individuals. It can play a significant \nrole in adapting women to hysterectomy.\nThis study is the first study to investigate the interde -\npendence adaptation of women after hysterectomy under \nthe guidance of RAM, which is a novelty aspect of this \nstudy. The findings of the present study explained the \nadaptation of women in the field of interdependence after \nhysterectomy, which can expand the existing knowledge \nin the field of compatibility with a hysterectomy and \ngynecological surgeries.\nThis study has two major limitations. First, this study \nwas based on the experience of participants who wanted \nto share their experience after hysterectomy, so there \nmay be other experiences that we have not been able to \ncollect. Second, we considered only the experiences of \nwomen who underwent a hysterectomy. The views of \nhusbands and other family members involved in women’s \nrelationships were not considered. This research has been \nconducted in an environment with different social and \ncultural structures due to the nature of qualitative stud -\nies. The number of participants is small and was selected \nby the purposeful sampling method. Therefore, general -\nizing the results may not be easy. In this regard, research-\ners tried to compensate for this limitation by moving \nbased on strict observance of the principles of qualitative \nresearch and accurate reporting of research steps and \nefforts.\nConclusion\nThe results of this study provide important information \nabout post-hysterectomy adaptive behaviors in the field \nof interdependence to family members as important peo -\nple in women’s life and health care providers and other \npeople as support systems. Based on this, nursing activi -\nties can be planned, and finally, the effectiveness of these \nactivities can be evaluated. The findings of this study \nshowed that women after hysterectomy feel a strong need \nto receive support from family members, health care pro-\nviders, and colleagues. Therefore, it is recommended that \na study be conducted with the presence of the husband, \nother family members, and health care providers who are \ninvolved in women’s socio-emotional relationships and \nexplore the views them.\nAcknowledgements\nThis article is part of the dissertation of Ph.D. in Reproductive Health and has \nbeen approved and funded by the Research Vice Chancellor of Mashhad \nUniversity of Medical Sciences, Iran, No. 970684.The authors would like to \nappreciate the participants in this study and the staff of the women’s clinic at \nGhaem and Imam Reza Hospital.\n\nPage 10 of 11Goudarzi et al. BMC Women’s Health           (2022) 22:40 \nAuthors’ contributions\nFG, RB, AE, and TKH designed the study. FG and RB conducted the literature \nsearch. FG, RB analyzed data in consultation with AE. FG wrote the manuscript. \nAll authors read and approved the final manuscript.\nFunding\nThis study funded by the Mashhad University of Medical Sciences (Grant No. \n970684) Mashhad, Iran.\nAvailability of data and materials\nThe datasets used and/or analyzed during the current study available from the \ncorresponding author on reasonable request.\nDeclarations\nEthics approval and consent to participate\nThis study received approval of the ethics committee of Mashhad Medical \nScience University (Code: IR.MUMS.NURSE.REC.1397.037). All the experiment \nprotocol for involving humans was in accordance to guidelines of Declaration \nof Helsinki in the manuscript. Participants received explanation concern-\ning the purpose and manner of the study. Prior to the start of the interview, \nconscious written informed consent was obtained to participate in the study \nand audio recording. To participate in the study, the right to opt-out at any \ntime and the right to confidentiality of all their information was reserved. Each \nparticipant was given a hypothetical code and names to keep their informa-\ntion confidential.\nConsent for publication\nNot Application.\nCompeting interests\nThe authors declare that they have no competing of interest.\nAuthor details\n1 Student Research Committee, Mashhad University of Medical Sciences, Mash-\nhad, Iran. 2 School of Nursing and Midwifery, Mashhad University of Medical \nSciences, Mashhad, Iran. 3 Nursing and Midwifery Care Research Center, Mash-\nhad University of Medical Sciences, Mashhad, Iran. 4 Department of Midwifery, \nSchool of Nursing and Midwifery, Mashhad University of Medical Sciences, \nMashhad, Iran. 5 Behavioral Sciences Research Center, Life Style Institute, \nBaqiyatallah University of Medical Sciences, Tehran, Iran. 6 Nursing Faculty, \nBaqiyatallah University of Medical Sciences, Tehran, Iran. \nReceived: 13 June 2021   Accepted: 1 February 2022\nReferences\n 1. Desai S, Campbell OM, Sinha T, Mahal A, Cousens S. 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J Couple Relationsh \nTherapy. 2013;12(1):58–72. https:// doi. org/ 10. 1080/ 15332 691. 2013. \n750078.\nPublisher’s Note\nSpringer Nature remains neutral with regard to jurisdictional claims in pub-\nlished maps and institutional affiliations.","source_license":"CC0","license_restricted":false}