A Qualitative Exploration of Factors Influencing Prostate Cancer Adjustment Among Older Adults: A Social Ecological Model

Abstract

This study investigates the multifaceted factors influencing adjustment to prostate cancer among older men in Esfahan, Iran, using the social ecological model (SEM) as a guiding framework. We employed a qualitative approach, conducting semistructured interviews with 19 men diagnosed with prostate cancer, aged 63 to 92 years (mean age = 71), and six key informants, including spouses and health care professionals. We thematically analyzed the data to identify challenges and facilitators in the intrapersonal, interpersonal, and environmental domains of the SEM. The findings revealed a dynamic interplay of factors shaping the adjustment process. Intrapersonal challenges included physical degeneration, psychological distress, stigma, and role reversal, countered by coping strategies such as adopting healthy habits and spirituality. Interpersonal dynamics encompassed family strain and denial, yet the presence of familial support and self-care significantly enhanced adjustment. On an environmental level, financial burdens and health care barriers posed significant challenges. The study furthermore highlighted critical issues like “dysmedication” and “body occupation” which impede effective coping. A complex network of personal, relational, and systemic factors influences the adjustment to prostate cancer among older Iranian men. We urgently need tailored, culturally sensitive interventions to address health care inequities, alleviate economic pressures, and enhance psychosocial support networks, thereby empowering older adults to navigate this challenging journey with greater resilience and dignity.

Introduction

Prostate cancer (PCa) is a major worldwide health issue (Zheng et al., 2023), especially in developing countries like Iran, where restricted access to screening and inadequate health care infrastructure intensify the cancer’s negative effects. Socioeconomic inequalities and cultural obstacles exacerbate the challenges of PCa, particularly among older adults from low- and middle-income demographics (Izadi et al., 2021). These obstacles impede early identification and efficient management, resulting in elevated morbidity and death rates. Projections suggest a 66% increase in PCa incidence in Iran by 2025–2026, highlighting the urgent need for comprehensive, culturally sensitive treatment systems (Borza et al., 2022; Resnick et al., 2013).

Despite advances in medical treatments, most PCa patients endure persistent physical and psychological side effects, including urinary incontinence, erectile dysfunction, and emotional distress. The challenges of aging, such as diminished mobility, loss of self-confidence, and greater dependence on caregivers, often compound these issues for older adults. Socioeconomic constraints—including financial hardships, low health literacy, and inadequate health care resources—further delay timely diagnosis and access to care. Both patients and their families, who often bear heavy emotional and caring responsibilities, experience heightened anxiety and sadness as a result of these delays (Cincidda et al., 2023; Irusen, 2023).

The interplay between aging and PCa adjustment presents unique challenges for older adults. Traditional masculine norms and cultural expectations often exacerbate psychological distress, as men may struggle with a perceived loss of independence and societal expectations of strength. In contexts where health care systems fail to address these nuanced needs, older men may experience heightened isolation. This underscores the critical need for culturally sensitive interventions that consider the intersecting roles of aging, gender norms, and cultural beliefs in shaping adjustment to PCa (Reis de Sousa et al., 2022; Sadeghi-Gandomani et al., 2017).

The social ecological model (SEM) provides a robust framework for understanding the multidimensional factors influencing adjustment to PCa. By examining individual, interpersonal, community, and societal influences, SEM captures the dynamic interplay of personal beliefs, cultural contexts, and environmental determinants (Ezenwankwo et al., 2021). In the Iranian setting, these factors often diverge from those observed in Western contexts, reflecting distinct cultural influences on health behaviors. With Iran’s aging population projected to constitute nearly a quarter of the total population by 2050, addressing chronic disease management within family-centered care structures has become increasingly vital (Afshar et al., 2016; Mehri et al., 2019).

By applying SEM to the Iranian cultural context, this study aims to elucidate the factors shaping adjustment to PCa among older adults. Specifically, it explores the interaction of individual, interpersonal, community, and societal dimensions, offering insights into the cultural and systemic determinants of adaptation (León et al., 2020). The findings seek to inform the development of tailored support systems that enhance psychological resilience, social integration, and overall well-being among this growing demographic.

Materials and Methods

Study Design and Participants

This qualitative exploratory study aimed to investigate factors influencing PCa adjustment among older adults in Isfahan, Iran. Using purposive sampling, the study recruited Persian-speaking men aged 60 years and older who had received a PCa diagnosis within the past 6 months. To ensure data quality and relevance, the inclusion criteria were as follows:

• Residency in Isfahan and proficiency in Persian.

• PCa diagnosis within 6 months of the study.

• Cognitive ability, defined as a score of 7 or higher on the Persian version of the Abbreviated Mental Test (AMT; Bastani & Beigi Boroujeni, 2019)

• Absence of metastasis to other organs.

• Provision of informed consent, including permission for audio recording and transcription of interviews.

Data collection was conducted from February 2022 to March 2023 across oncology and urology clinics in Isfahan, Iran’s third-largest city, with a population of approximately 5.4 million. This region features five primary oncology centers that collectively manage an estimated 11,000 new cancer cases annually (Roshandel et al., 2021). Participants were recruited from two oncology units and two urology clinics selected for their accessibility and resource availability. To enrich the data, six key informants—including spouses and health care providers—were also included, offering additional perspectives on participants’ support systems and interactions with health care services. A total of 24 individuals participated in the study, comprising 19 older adults, three spouses, and three health care personnel. Initial interviews were informed by a pilot study involving six participants from man-to-man discussion groups. Insights from the pilot study were used to refine the interview guide and ensure its alignment with the study’s aims.

Data Collection

Semistructured interviews were conducted using the SEM as a guiding framework. This approach enabled the exploration of factors at three levels:

1. Intrapersonal (Individual) Factors: Knowledge of PCa, emotional reactions, beliefs about adjustment, and coping mechanisms.

2. Interpersonal Factors: Family dynamics, caregiver support, communication, and social relationships.

3. Institutional and Environmental Factors: Accessibility of health care services, cultural beliefs, community resources, and socioeconomic conditions.

The interviews were conducted face-to-face in Persian, employing a semistructured format with open-ended questions. Insights gained from the pilot study informed the development of the interview guide and ensured alignment with the study’s objectives. Each interview lasted an average of 45 minutes (range: 30–70 minutes) and was audio-recorded using a Lander LD-71F voice recorder.

The study followed strict protocols to ensure reliable data collection and analysis. To foster candid responses, participants were provided with a quiet and comfortable setting for the interviews, and ample time was given for reflection and answering questions.

Data Analysis

Thematic analysis was employed to identify, analyze, and report patterns within the data. This process involved:

1. Transcribing interviews verbatim using Microsoft Word 2013.

2. Conducting a line-by-line analysis to identify semantic units and key themes.

3. Annotating significant phrases and coding them systematically using the “New Comment” feature.

4. Grouping codes into categories based on similarities and differences, then organizing these categories into overarching themes related to PCa adjustment strategies.

5. Revisiting and refining themes until data saturation was achieved, ensuring comprehensive coverage of participants’ experiences (Pandey, 2019).

To ensure a robust methodology, the selection of participants was guided by the ongoing analysis. For instance, when financial hardship emerged as a significant factor during initial interviews, additional participants with limited financial resources were included to explore these themes further. Written field notes and memos were included in the analysis and developed into concepts (Mihas, 2019).

Trustworthiness

The study followed established qualitative research standards to ensure trustworthiness (Larsson & Holmström, 2007). Prolonged engagement with participants included initial familiarization sessions to build rapport and encourage open dialog. Member checking was conducted with participants and three independent qualitative researchers to enhance confirmability and dependability.

Credibility was further strengthened through maximum variation sampling, capturing diverse experiences across different socioeconomic and cultural backgrounds. Special attention was given to culturally sensitive strategies, such as fostering trust and addressing potential stigma related to PCa, to create a supportive environment for candid discussions (Ahmed, 2024).

Findings

The study included participants aged 60 to 92 years, with durations of PCa diagnoses ranging from 6 to 96 months. Table 1 summarizes the demographic and clinical characteristics of participants, including variations in education level, marital status, occupation, number of children, income level, and time since diagnosis. This diversity provided a rich foundation for exploring the multifaceted factors influencing adjustment to PCa among older adults.

Table 1.

Demographic and Socioeconomic Characteristics of PCa Patients and Key Informants

ID Code	Age, years	Education level	Marital status	Occupation	No. of children	Income level	PCa in month
PCa 1	67	H	Married	Business man	3	High	18
PCa 2	76	H	Married	Retired	4	Middle	36
PCa 3	71	U	Married	Teacher	3	Middle	9
PCa 4	68	H	Married	Retired	3	Low	19
PCa 5	63	M	Married	Businessman	2	High	6
PCa 6	77	U	Married	Retired	6	High	12
PCa 7	67	P	Married	Businessman	4	Middle	10
PCa 8	64	M	Married	Unemployed	3	Low	72
PCa 9	75	M	Married	Casual laborer	4	Low	24
PCa 10	81	H	Married	Retired	5	Middle	96
PCa 11	66	M	Married	Tailor at factory	3	Low	7
PCa 12	70	U	Divorced	Engineer	1	High	8
PCa 13	69	U	Single	Accountant	0	Middle	20
PCa 14	72	P	Married	Farmer	5	Low	14
PCa 15	64	H	Married	Taxi driver	3	Middle	16
PCa 16	66	U	Married	Retired	3	Middle	9
PCa 17	84	H	Married	Retired	4	Middle	13
PCa 18	92	P	Widowed	Retired	6	Low	72
PCa 19	66	H	Married	Businessman	2	Middle	36
PCa W1	70	M	Married	Housewife	3	Low	—
PCa W2	69	H	Married	Housewife	1	Low	—
PCa W3	51	U	Married	Teacher	2	Middle	—
PCa M1	37	U	Married	Nurse	2	Middle	—
PCa M2	45	U	Married	Urologist	1	High	—
PCa M3	49	U	Married	Oncologist	1	High	—

Note. Prostate Cancer: PCa = Prostate Cancer; PCa W = Prostate Cancer wife; PCa M = Prostate Cancer Medical Staff; Education: p = primary school; M = middle school; H = high school; U = university.

Intrapersonal Factors

Intrapersonal factors, defined as individual-level attributes that shape behavior and adaptation, emerged as pivotal in influencing the adjustment process to PCa. These factors can include both constraints (e.g., prostatic degeneration, psychological distress, stigma and self-blame, role reversal, awareness void, and reliance on herbal remedies) and facilitators (e.g., owning one’s journey, holistic coping strategies, role renewal, PCa insight, and preexisting knowledge; see Table 2).

Table 2.

Intrapersonal Factors Influencing Adjustment to Prostate Cancer Among Older Adults

Intrapersonal constraints	Intrapersonal facilitators
Prostatic degeneration  Weight, shape, fatigue Psychological distress  Anger, anxiety, fear, depression Stigma and blame Judgmental gaze Role reversal  From caregiver to care recipient, retirement and financial Distress, traditional masculine norms, losing dignity Awareness void  Low education level, poor knowledge of PCa disease Reliance on herbalist remedies	Beyond the physical realm  Owning your journey, adopting healthy habits, physical revival Holistic coping  Divine trust, disclosure of experiences, maintaining an optimistic outlook, spirituality and transcendence Role renewal  Shifting duties, maintaining independence, engaging in financial planning PCa insight  Preexisting knowledge of PCa disease

Intrapersonal Constraints

Prostatic Degeneration

Participants frequently highlighted the physical toll of PCa, describing weight fluctuations, changes in body shape, persistent fatigue, and diminished physical vitality. These changes negatively influenced their quality of life and self-esteem, disrupting daily routines and independence. For example, one participant’s wife explained her husband’s declining energy levels:“My husband now sleeps almost all day and only wakes up for short periods of time. This problem is getting worse, which worries me. Should I continue to wake him up or let him sleep?” (PCa W2)

This passage highlights the physical difficulties encountered by patients as well as the mental burden and uncertainty endured by their caregivers.

Psychological Distress

Psychological distress emerged as a prominent constraint, manifesting through emotions such as anger, worry, fear, and depression. These feelings often obstructed participants’ ability to adapt to their diagnosis and amplified their sense of stress and isolation. One participant candidly articulated his emotional turmoil:

All I know is that I am not feeling well and am afraid. I am hoping someone can help me figure out what is wrong and make me feel better. (PCa 3)

Stigma and Self-Blame

Social stigma and self-blame constituted substantial obstacles to adjustment for older adult PCa patients, frequently resulting in feelings of isolation and insufficient support. Societal perceptions might exacerbate mental pain and deter individuals from seeking help. Participants shared:

When I found out I had prostate cancer, I felt like I was to blame for everything. (PCa 4)

I felt like everyone was looking through me when they told me I had prostate cancer. People my age often assume that illness finds you because you didn’t care enough to prevent it. (PCa5)

These narratives underscore the internalization of societal judgments, emphasizing the importance of fostering an inclusive and supportive environment to encourage older adults to seek help without fear of blame or judgment.

Cosmic Health Beliefs

The older adults attributed their health status to external forces such as fate or divine will. While these beliefs provided emotional comfort, they additionally fostered a sense of resignation, reducing proactive engagement in health care. One participant remarked:

It’s God’s will that I’ve ended up like this. (PCa 14)

Judgmental Gaze

Six participants refrained from seeking necessary support, fearing judgment for their diagnosis and treatment decisions. One participant revealed, “I didn’t talk about my disease because I thought people would perceive me differently if they did.” Suffering in silence is preferable to feeling judged every time I speak.” (PCa 7)

Reliance on Herbalist Remedies

Several participants turned to untested herbal remedies as perceived “safer” alternatives to conventional treatments, often delaying evidence-based medical interventions. A participant explained:

“My son, these modern medicines are all chemicals!”all chemicals! For an old man like me, a tasty“doosh-aan-de”[herbal tea] from our land is much better. (PCa 2)

This preference for herbal remedies highlights misconceptions about their safety and efficacy, emphasizing the need for culturally tailored health education that addresses these misunderstandings.

Role Reversal and Loss of Independence

PCa often resulted in role reversals, where participants transitioned from caregivers to care recipients. This shift was compounded by financial distress and the perceived loss of traditional masculine roles, significantly impacting psychological and social well-being. One participant shared:

I used to be the one that cared for everything; now I am the pillar of support. I wait for others to decide even the smallest details of my life. (PCa 4)

Awareness Void

Low literacy levels and limited formal education posed significant barriers to understanding medical information and treatment options among participants. This awareness gap hindered their ability to engage meaningfully in managing their condition. One participant admitted:

I can’t read the pamphlets they give me, and I don’t understand the doctors. (PCa 8)

This finding highlights the importance of using visual aids, simplified language, and verbal explanations to improve health literacy and support older adults in navigating their health care journey effectively.

Intrapersonal Facilitators

Beyond the Physical Realm

Adapting to PCa involves more than managing physical symptoms; the adaptation process includes promoting healthy habits, restoring physical health, and enhancing spiritual well-being.

Owning Your Journey

Active health management, including gaining knowledge about PCa, adopting positive lifestyle changes, and seeking appropriate support, emerged as key facilitators of adjustment. A participant remarked: “I feel in control of my life through talking to my family and consulting different doctors, which gives me strength and hope.” (PCa 7)

Healthy Habits and Physical Revival

Adopting healthy habits, such as balanced nutrition and regular physical activity, proved crucial for participants adjusting to their PCa journey. These behaviors not only helped manage physical symptoms but additionally supported their mental and emotional well-being. One respondent expressed his determination to renew his physical strength with the words, “When my wife told me to take care of my health, I looked at her and said, ‘I’ll rebuild this body’” (PCa 13). This statement underscores how committing to physical activity and self-care fostered a greater sense of control, resilience, and personal empowerment among participants.

Holistic Coping Strategies

Participants employed a variety of holistic coping mechanisms that addressed the multifaceted dimensions of their experiences, including physical, emotional, mental, and spiritual needs. These strategies, detailed below, provided participants with a framework to navigate the complexities of living with PCa:

• Divine Trust: Faith played a central role for participants from religious backgrounds, offering a source of comfort and strength. One participant shared, “We should face each day with hope and keep working—not letting illness or age bring us down. I find hope within myself” (PCa 19). This perspective underscores the importance of spiritual resilience in fostering optimism and persistence.

• Disclosure of Experiences: Sharing personal experiences with trusted family members, friends, or support groups proved therapeutic, alleviating emotional burdens and enhancing perceived support. One participant reflected, “I wasn’t able to tell my family about my illness, but I felt relieved after I talked to them, and my support and help were there” (PCa 15). This finding highlights the therapeutic value of open communication in fostering emotional relief and social connection.

• Optimistic Outlook: Participants identified maintaining a positive mind-set, supported by family and friends, as a cornerstone of their coping strategy. One individual stated, ‘With the support of family and friends and maintaining a positive outlook, I find inner strength to face prostate cancer, empowering me to take charge of my treatment” (PCa 1). Such an approach emphasizes the interplay between optimism and perceived self-efficacy in managing chronic illness.

• Spirituality and Transcendence: For some, spirituality transcended physical challenges, enabling them to achieve a sense of peace and acceptance. This was particularly evident in the context of mortality. As one participant poignantly described, “Now that I picture myself standing at the tail of this line, there is nothing to fear anymore. Death is not such an overwhelming thing as it is a rebirth. Meeting God would symbolize the conclusion of life (PCa 18). This perspective illustrates how spirituality can facilitate existential acceptance and emotional equilibrium.

Role Renewal

Adjusting to life after a PCa diagnosis required participants to renegotiate their roles and responsibilities, often fostering a renewed sense of purpose and identity:

Shifting Duties

Some participants embraced new responsibilities or adapted existing ones to maintain engagement and purpose. One participant, who continued to be active in business and tutoring, expressed, “I continue to engage in business dealings and tutoring.” (PCa 19)

Maintaining Independence

A strong desire to maintain independence emerged as a critical motivator, with participants striving to handle daily activities autonomously. As one respondent shared, “I try to be independent. Even at parties, I do things myself before the kids help. I vacuum, cook, and handle tasks on my own. I don’t want to burden anyone; I prefer to be self-reliant.” (PCa 6)

Financial Planning

Financial planning is crucial for individuals with PCa to maintain autonomy and renew their roles, despite rising medical costs and potential income loss. Proactive measures, such as finding a job, demonstrate financial autonomy, preserving self-efficacy and independence during adaptation. One participant shared his proactive approach: “I’ve found a job that will help me cover part of my costs. I am not dependent on others; being active means different things. Working shows that I’m active and engaged.” (PCa 5)

PCa Insight: Informed Decision-Making

Preexisting knowledge about PCa, termed “PCa Insight,” played a crucial role in enabling participants to make well-informed choices about their health. By providing reliable information on the disease, treatment alternatives, and ways to manage symptoms, this understanding empowered individuals to take an active role in their health care journey. One participant noted their reliance on social networks and medical websites for information, stating that: “I have used these social networks and doctors’ websites to find information on the disease, and I continue to use them whenever needed.” (PCa 12)

Interpersonal Factors

Interpersonal factors significantly shaped how older adults adjusted to PCa, with relationships and social dynamics playing a pivotal role. The support—or absence thereof—offered by family, friends, and caregivers emerged as both a facilitator and a barrier to adaptation (see Table 3).

Table 3.

Interpersonal Factors Influencing Adjustment to PCa Among Older Adults

Interpersonal constraints	Interpersonal facilitators
Family strain  Burden on the family  Dwelling on negativity / unimportant complaints (body-occupation) Dysmedication Family denial of cancer	Being the cane in hand  Accompanying during treatment  “Listening with heart and soul”  Leaning on someone Empowered support and self-care  Sharing the load  Taking charge of your health

Interpersonal Constraints

Family Strain

• Burden on the Family: The emotional and practical challenges of caring for a PCa patient often led to feelings of exhaustion and frustration within families. One participant candidly shared, “I observe the struggles they face due to my illness, which not only exhausts me but also frustrates them. Sometimes, I even think dying would be better for everyone.” (PCa 8)

• Dwelling on Negativity: The psychological impact of PCa furthermore led to strained relationships, with some participants expressing feelings of isolation and shame. A family member explained, “He always says, ‘Why is this happening to me?’I’m often ashamed to be with my friends. I prefer to be alone so no one sees how much I struggle.” (PCa W3)

Body Occupation

The phrase “body occupation” refers to the concern with minor health complaints or negative aspects of a condition, which can dominate the thoughts of patients and their families. unfavorable characteristics of a disease that may dominate the minds of patients and their family. This obsession often inhibited effective coping. One participant described this experience: “Urinary and sexual issues are a constant source of frustration for me. My worries overpower me, and I feel powerless.” (PCa 6)

This focus on bodily symptoms magnified their perceived severity, creating a cycle of worry and distress that left little space for constructive adjustment or positive engagement.

Dysmedication

“Dysmedication” refers to the over-reliance on medication as a sole management strategy, often neglecting emotional, social, and lifestyle interventions essential for holistic well-being. A participant expressed his frustration, stating, “When I go to the doctor, they only give me a few medicines. They don’t seem to care that I am old, sick, and live a long distance away. “They need to give more medicine.” (PCa 16)

Some older Iranians hold a cultural perspective that equates the quantity of prescribed medications with the seriousness of medical care, potentially leading to misplaced reassurance.

Family Denial of Cancer

Some individuals experienced rejection from family members regarding their diagnosis, which hindered their ability to communicate openly. One participant said, “They do not want to discuss my cancer or anything relevant at all.” (PCa 3)

This denial, although likely meant to shield the patient from discomfort, often resulted in emotional isolation and hampered collaborative coping attempts.

Interpersonal Facilitators

Interpersonal facilitators played a critical role in supporting older adults PCa through practical assistance, emotional reinforcement, and the cultivation of self-efficacy. These factors, such as empowered support, self-care, and the concept of a “cane in hand,” significantly contributed to the development of resilience and adaptability in the face of illness.

Being the Cane in Hand

Family support appeared as a critical component of participants’ capacity to overcome the problems of PCa. In this setting, family members served as a metaphorical “cane”—a continuous and dependable source of support throughout periods of physical and mental frailty. This notion included:

Accompanying During Treatment

Family members who accompanied participants to medical appointments provided more than logistical support; their presence offered emotional stability and reassurance. One participant reflected:

My family and friends supported me throughout the journey. They were there from the appointments to the treatments, offering a helping hand, a listening ear, and a cause to celebrate successes. Their unwavering support became the foundation of my strength and motivation. I shall be eternally thankful. (PCa 9)

Another participant expressed, “My illness is critical to them, so they make sure I eat and take my medicine. My family’s love means a lot to me, and they are now my crutches, truly the cane in my hand.” (PCa 14)

Listening With Heart and Soul

Empathetic listening can profoundly impact older men with PCa, often matching the therapeutic effects of medical interventions. Participants consistently emphasized the need to share their fears, worries, and vulnerabilities in an environment free from judgment. As one participant eloquently described:

They listened to me whine about anything and everything. They believed in me, even when I didn’t, and that made all the difference.” (PCa 2)

Leaning on Someone

The ability to rely on others—whether emotionally, physically, or practically—significantly alleviates the burden of severe illness. Participants expressed gratitude for the care and attentiveness of their families. One participant reflected:

My wife and children ensure I eat properly and take my medication on time. To them, my illness is a serious matter. Knowing my family loves and supports me means everything, and now they have become the crutches I lean on. (PCa 13)

Empowered Support and Self-Care

The involvement of family members in caregiving and their encouragement of self-care were pivotal in promoting successful adjustment to life with PCa. These forms of support extended beyond direct assistance to actively empowering participants in managing their health.

Sharing the Load

Collaborative caregiving among family members eased the burden on both the primary caregiver and the patient, reducing individual stress and fostering a collective sense of support. As one participant noted:

Family collaboration is a way of preventing the burden of my care from falling only on one person. (PCa 1)

Taking Charge of Your Health

Family support empowered participants to engage in self-care and health management more effectively. By providing guidance and emotional reinforcement, family members facilitated a sense of autonomy in participants. One participant explained:

With help from family, knowing how to “be in control of your health” is now easier and much more purposeful. (PCa 13)

Environmental Factors

Environmental factors significantly shape the adjustment process for older adults with PCa. These factors include barriers such as driving challenges, inflation, and systemic issues within health care, as well as facilitators like support from NGOs, private hospitals, government services, and educational programs (see Table 4).

Table 4.

Environmental Factors Influencing Adjustment to PCa Among Older Adults

Environmental constraints	Environmental facilitators
Navigating daily challenges  Driving hazards  Inflationary pressure Roadblocks to treatment  Rising healthcare costs  Paying for empty promises  Infantilizing care  Inadequate time allocation  overwhelmed with cases  Speaking a different language  Geographical disparities  Shortages of medications  Inadequate insurance coverage  Increased healthcare costs	Other community access  Nongovernmental Organizations (NGOs)  Private Hospitals and Treatment Centers  Government Services and Public  Supportive and Educational Programs

Environmental Constraints

Navigate Daily Challenges

Older adults with PCa must navigate daily challenges that disrupt their independence and financial stability, making the adjustment to illness more difficult. Two key constraints include:

Driving Hazards

Most participants rely on driving to maintain independence. Nevertheless, health complications associated with PCa, such as fatigue, mobility issues, and treatment side effects, often exacerbate driving challenges. One participant shared:

I have some vision problems, and I can barely drive. The cars are moving at high speed, and they are constantly honking next to me, making me afraid to drive. As a result, I have to leave my car parked. (PCa 11)

Inflationary Pressure

Rising health care costs, coupled with limited income, place an immense financial burden on older adults managing PCa. One participant reflected:

The pressure from inflation, low wages, and rising living costs is increasing daily. Add illness to this, and life becomes extremely challenging. (PCa 8)

Roadblocks to Treatment

Older persons with PCa confront multiple barriers to successful treatment, exacerbating their physical and mental issues. Financial strains, communication breakdowns, and structural shortcomings are the main causes of these obstacles to receiving high-quality treatment. key constraints include:

Rising Health care Costs

Patients and their families struggle to afford rising health care costs. One participant stated:

I have seen the cost of my treatment and medications skyrocketing. The family asked me to sell the house to cover the medical costs; I refused. (PCa 6)

Paying for Empty Promises

Participants mentioned that they are frustrated by health care professionals’ unmet expectations and inadequate treatments. One participant explained:

The financial burden of doctor visits, diagnostic tests, and medications falls entirely on the patient. Many doctors, driven by profit, prioritize treating minor cases over serious conditions. I’m spending money intended to support my family on medical expenses, yet the treatment often feels futile and ineffective. (PCa 13, 18)

Infantilizing Care

“Infantilizing care” reflects the tendency of health care providers to undermine the autonomy of older patients by oversimplifying information or disregarding their concerns. This approach diminishes the dignity of patients and undermines their engagement in care. One participant lamented:

They speak to me like a child, not taking my concerns seriously or explaining things properly. (PCa 15)

Inadequate Time Allocation

Health care providers, overwhelmed by high patient loads, often dedicate insufficient time to older adults with PCa, compromising the quality of care. As one participant recounted:

The doctor hastily prescribed medication without properly examining me for a prostate issue and immediately called in the next patient. (PCa 16)

Overwhelmed With Cases

Health care providers in public health systems often face overwhelming caseloads, leading to burnout and decreased quality of care.

Every time I visit a doctor, various diagnoses and prescriptions exist. Sometimes, I feel like going there to say “hi” rather than get a proper check-up. (PCa 2)

It feels like a public bathhouse. You come to the hospital, and they ask you to lie on a bed. Then they inform you that the radiation therapy device requires repairs and you should return in a week. (PCa 5)

Speaking a Different Language

Language barriers between health care providers and patients hinder efficient communication and decision-making, often leading to misconceptions about medical diagnoses, treatment options, and subsequent care. As a result, one patient remarked:

I don’t understand what these doctors are saying, so I end up taking my medications however I want. (PCa 8)

Geographical Disparities

Rural patients face financial strain, delays in essential treatments due to limited access to modern medical facilities, and environmental challenges such as weather, air pollution, and inadequate rest facilities. One participant described:

Patients from smaller towns must travel long distances in serious heat, with air pollution in Isfahan and a lack of rest facilities, all discouraging travel to the city. (PCa 14)

• Shortages of Medications.

Shortages of essential medications, including chemotherapy agents and hormone therapies, present a significant barrier to effective treatment. These shortages not only delay care but further increase the risk of adverse outcomes by forcing patients to rely on less effective alternatives.

A lot of people have to rely on Iranian medications because of the high costs. I use Iranian medicine because I can’t afford the foreign ones. (PCa 7)

Insufficient Insurance Coverage

Inadequate insurance coverage imposes a substantial financial burden on patients, often deterring them from accessing necessary treatments. High out-of-pocket expenses for tests, scans, and medications, along with contractual gaps between insurers and private health care providers, result in delayed or denied reimbursements. A participant expressed their frustration:

We have visited the insurance office several times and haven’t received any satisfactory response. For the last three months, I have been persistently pursuing reimbursement for scanning and testing fees; yet, some costs remain unpaid due to the absence of contracts with private centers. (PCa 4)

Environmental Facilitators

Other Community Access

Environmental facilitators play a critical role in bridging gaps in care and offering essential support for individuals with prostate cancer, especially in overcoming barriers to effective treatment. These facilitators include a variety of community resources:

Nongovernmental Organizations

Nongovernmental Organizations (NGOs) provide subsidized treatments, transportation assistance, and counseling services, particularly benefiting those facing economic hardships or geographic challenges. One participant noted:

A cancer charity at Seyyed Al-Shohada Hospital in Isfahan has always helped me with the costs of surgery and discharge, reducing my stress and anxiety about the illness. (PCa 12)

Private Cancer Treatment Hospitals

Private hospitals and treatment centers offer advanced medical care with shorter waiting times and access to the latest technologies and therapies. As one participant explained:

I go to a private hospital for all my medical needs. The reason is that they have better specialists and better equipment, so treatments are less risky. (PCa 19)

Government Services and Public Centers

Government services and public health centers provide accessible health care to all population segments through free or low-cost medical care, public health campaigns for early detection and awareness, and screening programs. One participant shared their positive experience:

I do my treatment at Seyyed Al-Shohada Medical Center, and they have excellent service. (PCa 1)

Supportive and Educational Programs

These programs, whether public or private, offer essential information about treatment options, lifestyle adjustments, and the overall adaptation process. An oncologist highlighted:

As an oncologist, the conferences at the Cancer Research Center are invaluable for staying current on the latest PCa treatments and diagnostics and exchanging ideas with fellow experts. (PCa M3)

Discussion

The unique cultural context of older Iranian adults shapes the complex socio-cultural adjustment to PCa in this study. While the SEM traditionally emphasizes the dynamic interplay of individual, interpersonal, and environmental factors, our findings highlight a culturally nuanced understanding of adaptation strategies specific to this population.

From an intrapersonal perspective, some participants demonstrated emotional resilience, a strong desire for independence, and reliance on spirituality and religious beliefs as key coping mechanisms. Participants often experienced a profound shift in life perspective, transitioning from a focus solely on disease and physical symptoms to seeking a deeper, more meaningful understanding of their experiences. This aligns with Gerotranscendence Theory, suggesting that older adults facing health challenges often shift from a materialistic to a more transcendental worldview, enabling them to prioritize self-reflection, inner growth, and role reassessment in later life stages (Tornstam, 1997). Iranian culture integrates religious traditions into everyday life, which are essential in cultivating hope and enhancing resistance against disease.

The study underscores the importance of selective social engagement. In accordance with socioemotional selectivity theory, as individuals age, they prioritize emotionally fulfilling relationships that provide meaningful support, especially when coping with health challenges. This selective focus on close, supportive relationships, grounded in cultural values, serves as a purposeful strategy for enhancing emotional well-being (González et al., 2023). By prioritizing quality over quantity in their relationships, older adults acquire significant emotional resources that enable them to confront disease with resilience and adjustment.

His research further emphasizes the relevance of Lazarus and Folkman’s stress and coping model, illustrating the significance of culturally specific coping strategies that extend beyond traditional emotion-focused and problem-focused methods (Aldwin et al., 2021). In Iran’s family-oriented culture, participants used methods such as patience, resilience, and positive thinking, demonstrating a culturally tailored method for treating sickness.

The study identifies intrapersonal constraints, including prostatic degeneration, chronic fatigue, and psychological distress, as substantial barriers to adjustment. Cultural pressures such as fear of societal judgment and existential anxieties exacerbate these challenges. For older Iranian adults, the intersection of aging and PCa adds complexity due to comorbidities and the cumulative impact of multiple health issues, leading to heightened vulnerability and diminished quality of life.

The unique challenges of aging and PCa necessitate tailored coping strategies. Physical limitations, reduced social networks, and cultural fears surrounding stigma often hinder individuals from seeking and receiving adequate support (Kazımoğlu et al., 2023). This highlights the importance of culturally adapted interventions that address the specific context of aging in PCa care. Our findings align with recent literature (Mardani et al., 2023; Matheson et al., 2020) on the adverse impact of physical and psychological changes in PCa patients. In contrast, this study highlights culturally specific barriers, like fear of social stigma and reliance on traditional remedies, that receive less attention in Western contexts.

Interpersonal dynamics within families played a dual role in the adjustment process. Supportive family environments facilitated coping and adaptation, consistent with studies by Collaço and Salomo et al. (Collaço, 2019; Salomo et al., 2023). On the contrary, family denial and pressure sometimes exacerbate distress. This duality underscores the importance of recognizing both positive and negative familial influences, particularly in societies where family plays a central role in caregiving (Akin et al., 2012; Xu et al., 2012).

Environmental challenges, such as health care costs, inflation, and limited access to advanced medical treatments, additionally posed significant obstacles for Iranian PCa patients. Our findings align with broader research on economic barriers in cancer care (Bucknor et al., 2021) and emphasize the role of NGOs, private hospitals, and educational programs as critical support structures. Educational and supportive programs, as highlighted by Ilie et al. (2023), empower patients and enhance resilience, suggesting a need for holistic care approaches that incorporate both psychological and social dimensions.

This study enhances the comprehension of adjustment mechanisms for older adults with PCa, specifically with the interplay of intrapersonal, interpersonal, and environmental elements. This study offers a more profound understanding of the culturally specific influences on adaptability, building upon prior research that examined the psychological and physical problems of PCa.

Conclusion

This study underscores the complex interplay between psychological resilience and cultural values in the adjustment process of older Iranian men with prostate cancer. Our findings reveal that these individuals often draw on Islamic and Eastern values, such as acceptance of fate (Qadar), spirituality, and maintaining hope, to interpret and respond to their illness. At the same time, they often face significant social challenges due to the perception of aging as a limitation. Inadequate interactions between health care personnel and older adults, especially in therapeutic settings, exacerbate these issues. Moreover, economic hardships and sanctions have restricted access to health care services, further weakening social and psychological support systems.

The limited role of the community in providing adequate support structures highlights gaps in current resources, emphasizing the need for multidimensional interventions. These should not only strengthen psychological coping mechanisms but also improve therapeutic interactions, address economic constraints, and enhance social support systems tailored to the needs of older adults with PCa.

Key factors such as over-reliance on medication (dysmedication), cultural perceptions of aging, and limited access to psychosocial resources profoundly affect the adjustment process. These factors interact within the social-ecological framework, manifesting at intrapersonal, interpersonal, and contextual levels. For instance, the phenomenon of “dysmedication” reflects a dependence on medication that overshadows the value of emotional and social support, a significant issue for this population.

Addressing these complexities requires culturally sensitive, multifaceted intervention strategies. Enhancing psychological coping mechanisms, fostering empathetic therapeutic relationships, reducing economic barriers, and strengthening social support networks are essential steps. Only an integrated approach can meet the diverse needs of underserved older adults with prostate cancer, ultimately improving their quality of life.

Limitations and Strengths

Limitation

This study faced several limitations, including potential researcher bias inherent in qualitative research and limited generalizability due to a small, nonrandom sample. The application of the SEM added complexity to the interpretation of results, requiring substantial resources. Despite employing strategies like triangulation to mitigate bias and enhance participant diversity, the majority of participants had secondary or higher education levels. This demographic skew may limit the generalizability of findings, as a significant number of older adults in Iran have lower educational attainment. Future research should include participants with a broader range of educational backgrounds to gain a more comprehensive understanding of the challenges faced by diverse older adults with prostate cancer.

Strengths

Despite these limitations, the study has several strengths. Its qualitative approach enabled an in-depth exploration of the experiences of older adults adjusting to prostate cancer, providing rich and detailed insights that would be difficult to capture using a quantitative approach. The application of the SEM offered a comprehensive perspective on the factors influencing adjustment, highlighting the interplay between individual, interpersonal, community, and societal elements. In addition, focusing on the specific cultural context of Esfahan enhances the understanding of how cultural and environmental factors shape health outcomes, offering valuable insights for developing culturally appropriate interventions.

Recommendations for Future Research

Future research should focus on understanding the evolving adjustment processes of older adults with prostate cancer, particularly in cultural contexts like Iran, and on developing culturally sensitive interventions that integrate psychological, social, and spiritual care. Comparative studies across cultures could help establish global best practices while respecting local values, ensuring that older patients receive dignified, compassionate care tailored to their unique needs.