Breast cancer (BC) is the most prevalent cancer amongst females all over the world (1). The highest prevalence of BC has been reported in Europe and the United States, while the lowest prevalence has been found among Asian and African women (2). In Iran also, BC accounts for the second cause of cancer-related death (3). In this country, the prevalence of this malignancy has been reported to be 29.88% per 100 000 women (4), mainly occurring in 45–65 and 80–85 age groups (5).

BC can be treated via surgery, chemotherapy, and radiotherapy, depending on the severity and stage of the disease (6). In some cases, mastectomy is performed to prevent BC metastasis (7), which involves the partial or complete removal of one or both breasts. This operation leads to the asymmetry of the breasts, a large scar, and change in nipple sensation. In addition, since breasts are orgasm able organs, can secrete oxytocin, and result in uterine contractions during sexual intercourse, their removal may be accompanied by a decline in sexual function (8), eventually exerting negative impacts on patients' mental, sexual, and social statuses (9). Changes in women's sexual behaviors can, in turn, affect their husbands' sexual functions and lead to various psychological consequences (10), which may even result in hospitalization and depression (11). Hence, BC is sometimes referred to as the relational cancer (12).

Support on the part of one's husband plays a key role in adaptation with BC. Supporting women can reduce their stress levels and improve their compatibility (13). It can also improve patients' problems associated with mental imageries, which can avoid depression (14) and promote the quality of sexual relationships (15). On the other hand, incompatible responses on the part of each spouse can expose the couple to serious challenges in their marital relationships (14). They can endanger the family's function, as well (15). One of the prerequisites of supporting one's wife is adaptation with her disease (12). Thus, investigation of adaptation and its dimensions can play a critical role in improving the disease process. In consultation sessions also, adaptation and its dimensions can be taught to patients in order to facilitate their acceptance of the disease, adoption of positive adaptation strategies, and return to normal life (16). In this way, steps can be taken toward the timely diagnosis of mental status among husbands (17).

There are several questionnaires including the Ways of Adaptation Checklist developed by Lazarus and Folkman (18), Tobin's Adaptation Strategies Inventory, Adaptation Inventory for Stressful Situations (19), and Adaptation Strategy Indicator (20), which can be utilized to assess adaptation with stress. Some other questionnaires designed in this context include adaptation with chronic pain (21), sexual pain (22), cancer (23), and family adaptation with eating disorders (23). These questionnaires were developed between 1983 and 2016 and were translated to other languages afterwards. Additionally, these questionnaires are mostly one-dimensional, while cancer can lead to mental, social, and sexual disorders. Hence, it is better to make use of an instrument encompassing all these dimensions (24). Since cultural variables play an important role in adaptation, the intended instrument should contain the inter-personal, cultural, and belief contexts, as well (25). Afterward, In Iran, the religion of Islam and the law allow the husband to remarry if the woman is diagnosed with cancer Or divorce his wife (26), but such permission is not given to Iranian Muslim women to divorce and have sex with another man if the husband is diagnosed, which in some Iranian views is gender discrimination (27). Based on what was mentioned above, the present study aims to design and validate Adaptation Questionnaire among the Husbands of Iranian Muslim Women with Breast Cancer (AQHIMWBC).

The methods used in the designing and validating of the questionnaire are based on current best practices (28).

The analysis of the quantitative part led to the extraction of 4 dimensions: physical problems, self-concept of role playing and interdependence. In the dimension of physical problems, attention was paid to disorders created in all body systems. In the dimension of self-image, attention was paid to the attitudes, beliefs, spirituality, ideals, mental and physical perceptions of the husbands of women with BC. In the aspect of role playing, attention was also paid to the roles of child, wife, job and all situations that assign tasks to an individual. Also, in the dimension of interdependence, analysis of relationships, all support systems and their aspects, support failures in the husbands of women with BC were mentioned.

After developing the primary items of the scale, its content and face validity as well as its reliability (internal consistency) were assessed.

Based on the results presented in Table 1, this study was conducted on ten husbands, nine patients, four therapists, and one patient's mother. The majority of the participants had academic degrees and had been married for more than 20 years. Additionally, more than 10 years had passed from the diagnosis of BC in most of the participants. The patients had undergone total mastectomy and had no history of metastasis.

The qualitative content analysis revealed four main categories, 18 generic categories, 63 subcategories, and 179 codes. Thus, the initial scale was developed with 79 items. After the assessment of qualitative face validity, 50 items were reviewed and revised. Then, quantitative face validity was evaluated, in which all the items received scores above 1.5 and remained unchanged. After calculating the CVR, 20 items were eliminated due to receiving scores below 0.56. After that, CVI was computed as >0.79 for all the items. Thus, all the 59 items were considered for the assessment of construct validity. Based on the participants' feedbacks as well as the reviews performed by the researcher and the supervisor, items 10, 12, 13, 14, 22, 24, 25, and 52 were removed, and a 51-item scale was developed. Considering KMO = 0.746 and Bartlett's test = 12,398.085 at the significance level of 0.001, the variables were appropriate for factor analysis.

Since six factors obtained eigenvalues > 1, six factors were approved by factor analysis (Figure 1). Based on the results, the six factors explaining a part of the total variance were extracted (Table 2). According to varimax rotation, these six factors explained 51.71% of the changes in the scale variables (Table 3). Furthermore, < 15% of the respondents obtained the highest and lowest possible scores in these six factors, and the scale presented no ceiling or floor effects.

The Cronbach's alpha coefficient was found to be 0.931, 0.893, 0.855, 0.745, 0.726, and 0.883 for factors 1, 2, 3, 4, 5, and 6, respectively. This measure was also computed as 0.912 for all the factors. Additionally, the split-half correlation coefficient was computed as 0.933 for factor 1, 0.888 for factor 2, 0.834 for factor 3, 0.704 for factor 4, 0.711 for factor 5, 0.852 for factor 6, and 0.701 for the entire factors (Table 4).

The influence of religion on adaptation is very clear (31) and it can affect the compatibility of people from the point of view of the incidence of the disease to its treatment (32). In addition, culture is another effective factor in compatibility, and in cultures where there is gender discrimination, some couples are able to transcend culture and achieve better compatibility (33). Considering that the most common religion in Iran is Islam (34) and the family laws in Iran are such that the husband should not have another sexual partner without marriage (35). And on the other hand, if a woman is diagnosed with cancer, her husband is allowed to remarry (36), adaptation and its dimensions in Iranian Muslim husbands can have different dimensions. This study aimed to design and validate AQHIMWBC. The final version of the questionnaire included 51 items divided into six dimensions, namely role play, physical disorders, mental tensions associated with economic problems, marital relationships, perceived support, and anticipatory anxiety. In Roy's model, adaptation consisted of four dimensions (physical needs, self-concept, role function, and interdependence) And the set of fears, anxieties, worries are located in the dimension of self-concept due to various causes (29). In the present study, however, Fear of the future and mental tensions related to financial toxicity were allocated to two separate dimensions.

The first dimension obtained in the present study was role play. Accordingly, the husbands tried their best to perform their roles as a husband, father, and worker, so as to manage their wives' disease. In other words, they did their best and tolerated all challenges, pains, and sufferings (16). In contrast, some of the husbands acted passively and considered patient care as being imprisoned in the house, which prevented them from fulfilling their occupational responsibilities (17). However, other studies indicated that husbands considered their supportive role a priority in the treatment of their wives and made genuine attempts to direct their negative emotions through the measures they took. They supported their wives through focusing on their emotions and taking care of them, cooperation in the recovery process, management of the family, and helping them return to normal life (37).

The second dimension of the designed scale in the present research was physical problems such as insomnia, decreased desire to eat, hypertension and heart palpitations. Perndorfer reported the reduced duration and quality of sleep as two major problems among women's husbands, which were related to the fear of cancer recurrence (38).

The third dimension of the scale was related to psychological tensions related to economic problems. Similarly, other studies found that almost one-third of husbands faced financial difficulties and had to work extra hours due to their spouse's illness (39). Also, some of them have suffered financial poisoning, and factors such as the COVID epidemic (40) and sanctions (41) have aggravated this issue, and the cost of treating patients has increased greatly, causing the patient's incomplete treatment to be stopped (42).

The fourth dimension of the scale was related to marital relations. In this context, most of the husbands reported reduced sexual relations and pointed out that women cover their heads and breasts during sex, which reduces the quality of sexual relations, and breast cancer is referred to as relationship cancer (14). This can be attributed mainly to alopecia and mastectomy, which lead to a decrease in the sexual attractiveness of women from the perspective of husbands (43). In this study, some of the patient's husbands left or chose another sexual partner, which is considered unethical and betrayal from the patients' point of view Evidence suggests that women with BC reported a wide range of husbands' behaviors, from fidelity to infidelity, with patient abandonment indicating insufficient husband support for the patient (44).

The fifth dimension is the scale of support perceived by people around, governmental and non-governmental organizations, insurances, therapists in terms of mental, financial and spiritual. Although younger husbands show more tendency to receive support, few studies have paid attention to and evaluated the support of the husband (22), While the all-round support of the husband increases the patient's survival (45).

The sixth dimension of the scale was fear of the future, which mainly resulted from cancer recurrence. This issue has been confirmed in other studies, as well (38). This type of fear can range from mild to severe degrees, and becomes more intense when one's acquaintances are informed about the patient's cancer recurrence (46). Another reason for the fear of the future was financial concerns, which usually increases with the progress of the disease (47), and factors such as sanctions (48) increase their worries.

Based on the study findings, the designed adaptation scale has an appropriate reliability and validity and can be used amongst Iranian Muslim husbands. One of the main advantages of this scale is that, on the contrary to the previous instruments, it is not one-dimensional and encompasses all the dimensions of adaptation. Additionally, it has been designed on the basis of the target group's experiences. Finally, its reliability and validity have been assessed accurately. Yet, development of a new tool and evaluation of its psychometric properties require continuous processes and, consequently, further attempts are required for improving the designed scale. The researchers also hope to overcome the probable shortcomings related to the scale in future. Performance of confirmatory factor analysis is warranted, as well.

One of the limitations in designing of AQHIMWBC was that due to the corona pandemic, most of the interviews were conducted by telephone and the researcher was introduced to the virtual participants, which may affect the participant's sense of trust, although the researcher did his best before the interview. To create a sense of trust in the participants and by participating in patients' web-based groups and introducing them to prominent group members, this issue was largely resolved.

Considering that most of the participants had been married for more than 20 years and more than 10 years had passed since contracting the disease, it indicates the stability of marriage and the risk of low recurrence in BC survivors, and it reflects long-term compatibility, which is another limitation of the research.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The study received approval by the Ethics Committee of the Vice-chancellor for Research Affairs of Ahvaz Jundishapur University of Medical Sciences (ethics code: IR.AJUMS.REC.1399.099). All participants gave their written consent via web. The patients/participants provided their written informed consent to participate in this study.

MBBSH and NE wrote the main manuscript text. MBBSH prepared Tables 1–4 and Figure 1. All authors contributed to the article and approved the submitted version.