Challenges Facing Women Caring for a Spouse Having Cancer Treatment: A Critical Literature Review

Introduction: Cancer affects patients and families, especially female spouses. Female carers are affected emotionally, psychologically, spiritually and phys-ically. Challenges while caring for husbands with cancer include: higher stress; poorer health-related quality of life; emotional strain; impaired immune system; low appetite; high blood pressure; depression and anxiety. Female spousal carers also experience satisfaction that they rendered appropriate care to their spouse. Aim: To analyse challenges facing women caring for a spouse on cancer treatment. Method: Systematic critical literature review through CASP. Thematic analysis of data. Results: 16 studies met the inclusion criteria; 12 were selected by critical analysis. 4 themes emerged: “Quality of marital relationship”, “Effective communication”, “Carers” burden and need for support’, and “Coordination of care among providers”. Discussion: 4 themes are discussed in detail and related to literature outside the review. Conclusion: Women caring for a spouse on cancer treatment is affected by the cancer, symptoms, hospital admission and caring. They withhold information from their spouse to protect him. They have poor quality of life and poor health. HCP rarely recognize their role or needs.


Justification for the Study
Carers' experiences depend on the nature of their relationship with the patient [11]. Blanchard (1997) recommends more research to understand better female carers' experiences so that healthcare professionals can develop interventions and guidelines to support and prepare spousal carers to care for loved ones with cancer [13]. Women are more involved in care of their spouses than men are, performing more household chores and personal care than men do [19]. Knowledge of their challenges will provide evidence for health workers, for global practice and for hospitals' policies on carers and their roles.

Research Question
"What are the challenges facing women caring for a spouse having cancer treatment?"

Research Objectives
1) To appraise literature on challenges facing women caring for a spouse on cancer treatment, and thereby identify main themes on challenges of female spousal carers.
2) To evaluate the research and identify gaps in the existing body of knowledge.
3) To discuss implications for an oncology setting and make recommendations.

Preliminary Literature Review
The preliminary literature review identified needs for information, emotional support, practical support with daily life, and good patient medical care.

Need for Information
Carers of cancer patients want to be honestly informed about everything happening to their patients from the time they are diagnosed [20] [21] [22] They want information about diet, lifestyle adjustments, how to support patients and how to have time to discuss their condition with Healthcare Personnel (HCP) and other carers in a similar situation [22]. When a patient is diagnosed with cancer, they have several problems, due to the symptoms, side-effects of treatment and disease progression and recurrence; these must be told in good time to both carer and patient [22] [23] [24]. Carers may not want to talk about the illness with HCP, and instead may opt to talk about other things such as hobbies and family issues [25]. Patient problems may overwhelm both patients and carers emotionally and socially, and they have to be made aware early of how to deal with this [22]. Several factors contribute to carers being under-informed of their patients' illness: not being near the patient during doctors' visits, being unable to read what is in the file, being unable to ask HCP, and not understanding medical language [22]. It is important to meet carers' need for information.

Need for Emotional Support
Carers need emotional support at critical times: diagnosis, disease progression, and cancer recurrence [22]. Emotional support to carers differs according to cultures and socio-economic status [25]. Carers need enough time and a comfortable, private environment while being told of the diagnosis and treatment plan, as they need to be relaxed [22]. Carers expect HCP to be aware of their psychological and emotional needs and devise appropriate measures to help or refer to others [11] [20]. Carers do not want a lot of information during the diagnosis period as it is very hard for them to process it due to distress [26]. Several factors hinder carers from receiving adequate emotional support, including their inability to express their fears and concerns to HCP, lack of knowledge of who to contact and lack of openness about the disease between carer and patient [22]. Carers need emotional and psychological support.
patients and manage household resources. Formal support includes support from specialized HCP [27], but carers do not normally know where to get support in the hospital and if it is suitable for them as they are not fully informed about it [26]. Practical support that carers need includes transport, nursing care assistance, pain management drug administration, paid leave from employment, financial support, cleaning and continuous supplies of catheters, colostomy bags and incontinence pads [22] [26]. Factors that lead to carers not obtaining practical support include the increased caring burden and inadequate information on availability of services and how to access them [22] [23]. Caring for a cancer patient is overwhelming because it is added to existing household roles: hence the need for extra support.

Good Medical Care for Patients
Carers need to see that their patient is receiving good medical care [22]. They accompany patients to doctors' visits to support them, learn about the patient's care plan, and ensure that patients give accurate information to HCP. Carers feel satisfied when helping monitor their patient's condition [22] [27]. Sometimes carers do not receive medical support due to their fear that reporting dissatisfaction with care will negatively affect the patient and fear of talking about sensitive issues [22] [27]. Carers need the best possible medical care for their patient and good communication.

Research Methodology of Critical Literature Review
Critical literature reviews are vital to maintaining standards of evidence-based practice and healthcare [27]. A literature review is a comprehensive study to interpret the results of literature relating to a specific topic [28] [29]. For a literature review to be undertaken, there is need first to identify the research question, then perform a literature search and analyse the significant literature systematically [30]; the more specific the research question, the more focused the literature review [31].

Methods
The methods involved reviewing 31 studies, of which 16 discussed challenges of carers caring for their patient with cancer; of these, 12 were selected for detailed analysis: 5 prospective cohort studies, 3 qualitative studies and 4 literature review articles.

Search Strategy-Electronic Database Search
A first search was conducted during the preliminary literature review to identify gaps in the literature and a second to identify articles for review. The researcher performed database searches on PUBMED, CINAHL and Journals for health and social care (Table 1).

Search Terms Used
Medical Subject Headings (MeSH) were used to identify key terms and synonyms. Search terms for the Boolean search were: female carers, challenges, men with cancer and cancer (Table 2).
To manipulate key search terms Boolean logic "OR", "NOT", "AND" and truncations such as "car*" were used to bring out different nouns, spelling and synonyms [28].

Boolean Searches 1 and 2
Boolean searches 1 and 2 were done with the key terms using Advanced Search and All Articles (Tables 1-4).
In Boolean search 2, other search terms were added to further narrow the search ( Table 4). The different searches were combined (#1 AND #2 AND #3 AND #4 AND #5) to identify results.    (Table 5).

Inclusion and Exclusion Criteria
Studies included in the critical literature review were relevant to the research question (Table 6).

Additional Means of Searching
In addition to the electronic database search results, PubMed and Science Direct had a provision to show similar articles and some articles were extracted from there, to give a thorough search. This enabled the researcher to get literature that did not come out of the search process and it allowed for a thorough and complete search.

Selection of Data for the Review Process
The inclusion and exclusion criteria were applied to select final results for critical literature review. Of 16 studies, 12 were appraised using Critical Appraisal Skills Programme (CASP) ( Table 7).

Use of Critical Appraisal Framework
The articles finally selected for review were critically analysed using CASP tools [33] [34] [35]: Qualitative study tool, Cohort Study tool and systematic review tool.

Data Analysis
Step    Through "similar or related articles" -2 Step 2: Generation and assigning of codes Codes were generated from the main findings and discussion points of each article and again after summarizing articles' main outcomes. Then codes were assigned to each outcome.
Step 3: Developing themes Similar codes were grouped together and organized to enable the development of themes. The process was repeated several times until all codes were grouped to develop provisional themes.
Step 4: Comparing codes and themes The themes were visited several times to ensure that the themes were in accordance with the codes. Some new themes and codes were developed in the process.
Step 5: Definition and naming of themes Developed themes were individually examined and narrowed further to avoid repetitions and ensure they represented the data. Names were given to 12 themes.

Data Synthesis
Data synthesis of findings is the final stage of the research process to develop the research report. Literature findings were compared for similarities and inconsistencies. Inconsistent data was reviewed in detail for quality of research, which explained the few inconsistencies found.

Results
31 studies were found in the search. 16 articles that specifically discussed challenges of carers caring for their patients with cancer were considered. 12 of these were relevant and of good quality: 5 prospective cohort studies, 3 qualitative studies and 4 literature review articles. These were critically analyzed using CASP, ensuring that studies had good methodology and quality. Assessing the quality of studies included examining the study populations, designs and methodologies. Table 8 summarises the critical analysis.
To explore cancer patient family carers' physical and psychosocial health problems

Literature review
The burden related to caring emerged due to many responsibilities that female carers had in addition to their role as carers Authors did not assess the validity and reliability of instruments they used in their review to determine symptoms. Self-reported problems' frequency was not quantified in the review Kim

Study Population
Studies included in the review did not specifically target women's challenges, but couples' challenges, but differences in their challenges were described, enabling the researcher to capture information of interest [ [44]. All studies clearly stated their population description.

Recruitment Methods
Articles included in the review recruited participants from communities, rural comprehensive centres, a chemotherapy unit and outpatient clinics in hospitals.
The 5 cohort studies and 3 qualitative studies had similar recruitment strategies.
The 4 literature reviews did not specify the recruitment strategies as they are secondary data research articles. One of the 4 reviews did not have a section highlighting the methodology, search strategy, and illustrating how the reviewed articles were selected [38]. 2 qualitative studies used convenience sampling which enables the researcher to find participants who are readily available to participate in the study [28] [30].

Sample Size
To achieve validity, reality and confidence in the results, large samples are normally taken in quantitative research [28] [30]. Sufficient large numbers of participants are required for cohort studies to enhance confidence of the results [28] [30]. In qualitative research studies, snowball, theoretical and purpose samplings are used and the sample size is relatively small to extract data which is manageable from the interviews from a targeted population [28] [30]. The five cohort studies had sufficient numbers at first follow-up, except two which had poor

Study Design
The 12 articles had their aims clearly defined and their study designs matched the aims.

Qualitative Studies
Three out of 12 studies used qualitative research methodology [39] [42] [43]. ways of coping of carers of cancer patients on chemotherapy [42]. The study is of good quality, and data collection, interpretation and analysis were appropriate.

Prospective Cohort Studies
Five out of 12 studies used prospective cohort methodology [

Methodological Procedures
The authors in the 5 cohort studies ensured that before utilizing measurement scales for the study, they were adequately measured [

Analysis
Common themes were developed from research results through thematic analysis. These themes are presented and discussed in the following subsections while answering the research question.

Thematic Analysis and Key Terms Identification
4 themes arose from critical analysis: "Quality of marital relationship", "Effective communication", "Carers" burden and carers' need for support' and "Coordination of care among providers" (Table 9 & Table 10).   [41].

1) Importance of a good marital relationship
Couples dealing with cancer with a healthy marital relationship had a good Quality of Life (QOL), whereas those who do not have a good marital relationship or are single experience poor mental and physical health, carer burden, distress and a low QOL and most may need external support; relationship quality of close friends and intimate partners has a positive influence on QOL outcomes [17]. The couple's relationship quality is directly affected by intensity of pain and quality of the relationship may lessen negative effects of pain; the QOL of both patient and partner is affected by financial concerns but the relationship quality is not affected [16].  which aimed to explore experiences of carers both female and male while reviewing differences for their spouse with cancer using the stress process, suggests that the illness state of the patient and care demands were considered primary stressors, while spouses' roles and their marital relationships which comprises social and emotional support, employment attributes during illness, unstable financial life, poor self-perception, disturbed sleep pattern, interruption in life schedule and lifestyle were considered secondary stressors [41].
However, the researcher focused only on published research rather than unpublished "grey" literature, a weakness which means that some relevant literature may have been left out (Bowling 2014) [30].
Li and Loke (2013) revealed that marital adjustments were seen in couples who supported each other during the illness and marital satisfaction was closely associated with patients' physical and mental health status and not the carers' physical and mental health status [40]. The study suggests that emotion-focused coping, role adjustment and marital satisfaction are interrelated factors that influence reciprocal support between a spouse and her husband with cancer. The study concludes that patients' problems in adjusting their roles emerge from their hopelessness and spouses' issues with role adjustment, which in turn emerged from spouses' level of marital satisfaction and their own role alteration problems [40]. as they render their health services [17].

3) Personal Satisfaction
Mossin and Landmark (2011) reveals that personal satisfaction is voiced by spouses of cancer patients, as being there for their husbands was satisfying and they said that they could not miss that opportunity for anything [39]. Their experience allowed them to cope well during bereavement and preserve good memories of their husbands. This correlates with Li et al. (2013) which also shows that personal growth is a positive sign seen in women more than in men [41]. The study also revealed that spouses of men with advanced cancer disease were very anxious compared to spouses of men with cancer disease which has not advanced; this was more related to the condition of the patients and high demands of care by the patient [41].
a) Personal desire to care for a partner Mossin and Landmark (2011) report that the uncertainty of spouses about their role in the whole healthcare system and in the hospital was disheartening, as spouses thought that they were not being recognized, and talked less of identifying their emotions as they took care of their husbands [39]. The study sample in this case is a group of Norwegian women and generalisation of results may be limited as there could be cultural differences with other countries. Mossin and Landmark (2011) reported that despite lack of recognition in their role as carers, women overlooked the way they were considered by HCP and were there for their husbands throughout the hospital stay and had such great desire to support their husbands [39]. Male partners stated that support from spouses was positive, as it maintained their identity and self-esteem and women felt an active part of the team in care of their husbands [39]. Li and Loke (2013) state that higher self-efficacy, rated in terms of physical activity in both patients and spouses, was associated with the couple's good adjustment towards the illness, less anxiety, reduced carers' strain and good mental wellbeing [40]. However, the review revealed that spouses with lower self-esteem viewed the role towards their patients negatively. Similarly, Mystakidou et al. (2013) states that high anxiety levels are more common in carers with low self-esteem than in carers with high self-esteem [46].  Kim and Carver (2007) evaluate qualities of attachment of spouses of survivor cancer patients, and assess aspects of care provided to patients and how carers provided the care [18]. They explore the relationship between attachments to patient care tasks and sex differences (Kim and Carver 2007) [18]. They hypothesised that the security of attachment closely relates to the frequency of spouse involvement in patient care, and hence low levels of carer burden. On the other hand, they hypothesised that avoidance of attachment is closely related to lower frequency of spouse involvement in patient care, and hence high levels of carer burden. They go on to assume that attachment anxiety closely relates to frequency of involvement in patient care but high levels of caring burden [18]. Kim and Carver (2007) study was done on participants who were fluent speakers of English or Spanish, and therefore generalisability of the results is limited to carers who are educated, affluent and Caucasian carers [18]. The study reports that carers with attachment avoidance have problems in rendering emotional care to their partners with cancer, and these carers would benefit from health education interventions, good communication, and empathetic listening to help them provide emotional support to their partners, and should be advised to use family or community resources available to them [18]. Braun et al. (2007) recommend that HCP should be sensitive in dealing with carers, as their role as carers is based on their attachment orientation, and high levels of depression are associated with higher carers' attachment anxiety and avoidance [17]. Morgan et al. (2011) suggest that carers of advanced cancer patients have a high prevalence of depression, predicted by the use of the subjective caring burden and relational variables which are the carers' attachment orientation [16].

5) End of life carer experiences
One study brought out an important issue of end of life experience of carers [39]. Mossin and Landmark (2011) qualitative study explored experiences of spouses who are present with their loved ones in the hospital during their last days before death. Different themes emerged from the study, the main one being maintaining presence, either for one's own sake or for the patient's sake to ensure that the couple's relationship is maintained despite the husband being admitted to hospital [39]. Spouses were not even willing to be at home and the spouse's presence seemed to calm the patient and give them the desire to be with their wife all the time [39]. Support to patients was regarded as direct support and was appreciated, in that good quality of care to the patient showed that the couple was supported and the patient received good pain and symptom control [39]. Mossin and Landmark (2011) reported that despite their husbands' illness, none of the spouses discerned that their husbands would die during the admission in the hospital, and understood being there for their husbands as a normal extension of married life [39]. Termination was a very difficult time for spouses, as it not only stopped the caring role of the women but also the end of their marital relationship [ (2013) show that the Quality of Life (QOL) of couples dealing with cancer is improved with good communication from the HCP around cancer [40]. A reduction in uncertainty and the negative outcome of the illness improve patients' and spouses' QOL. Mossin and Landmark (2011) reveal that HCP behaviour, such as talking to spouses or good communication skills and physical contact such as greeting and showing concern, contribute positively to the patient and their spouses, as they see the team's consideration towards them [39]. Conversely, Kimberlin et al. (2004) highlight that carers complain that healthcare providers were not allowing them to be knowledgeable about their patient's illness, and this is frustrating [43].
3) Summary of theme 2 HCP tend to ignore female carers of cancer patients by informing only the patients and not informing and updating carers about patients' information, a practice that is so discouraging to female carers, because it is important to keep carers well informed about their patient's illness, extent and current state. Good communication skills of reassurance, greeting and showing concern have positive impacts on female carers and on patients with cancer.

1) Carer tasks
The 6-month cohort study of Nijboer et al. (2000) reveals that the effect of carer burden on carers' self-esteem and on interrupted diary roster decreased over 6 months [15]. Carers derived less self-esteem from caring, and care offered to patients was perceived as less interruptive over the 6 months. However, Stenberg et al. (2010) report that the burden related to caring emerges due to many responsibilities that carers have and in addition to their role as carer [44]. Caring consumes a lot of time as patients need support in activities of daily living, emotions, company, monitoring symptoms and transporting the patient to hospital [44]. Carers find it hard to balance this with meeting needs of other family members who are not sick [44].

2) Psychological effects a) Psychological problems experienced during caring
Carers of advanced cancer patients have high prevalence of depression, which can be predicted by use of the subjective caring burden and relational variables which are the carers' attachment orientations and marital dissatisfaction; high levels of depression are associated with higher carers' attachment anxiety and avoidance and 49% of spousal carers reported psychological effects, including feelings of sadness, powerlessness, depression, fear of loss of a loved one, distress, anxiety, shock, hopelessness, suffering, weakness, guilt, irritability in the caring process, and mood disturbances [17]. Emotional distress is evident in carers who perceive the patient's illness negatively irrespective of the patient's condition or the patient's view of the disease status [38]. The correlates with Li and Loke (2013) who report that psychological distress is evident in couples, as they have depression, stress and poor physical health, closely related to age of the  [40]. Spouses who use avoidance technique as a coping mechanism have psychological problems, and age, female gender and personality compound the problem [38]. This relates to Moser et al. (2013) which assesses emotional distress in cancer patients and their partners and how these relate to each other; their study was done over 3 years, after cancer diagnosis [45]. Prevalence rates for anxiety and distress upon diagnosis varied from 15% to 36%, and rates were lower in patients who are either male or female than in their spouses [45]. Depression rates which were clinically significant were higher in female partners than female patients, male patients and male partners, and over time depression declined in all groups [45].
After 3 years, a follow-up assessment on a small group of female partners, 3% of the sample population, discovered that they still suffered from distress which was clinically significant, compared to patients of both sexes and male partners [45]. b) Psychological support Carers raise the need for psychological support from their sick partners, HCP and family and friends, to help them cope during the caring process [42]. Spouses state that being around their husband during his hospital stay is necessary as it helps them feel at peace and calm, showing that spouses suffer a great deal when their husbands are suffering from cancer, and allowing them to be around their husbands during a hospital stay is necessary to their psychological wellbeing [39]. Braun et al. (2007) recommend that HCP create, plan patient and implement carers' couple interventions, integrating them to healthcare [17]. Stenberg et al. (2010) explore cancer patient family carers' physical and psychosocial health problems reported in literature, and discover how carers describe their responsibilities and problems [44]. Carers of cancer patients experience physical problems such as pain, loss of strength, sleep problems, appetite loss and loss of weight [44]. This correlates with Sercekus et al. (2014) who explore the needs, challenges and ways of coping of carers of cancer patients on chemotherapy treatment. Carers go through physiological effects of caring, such as weight loss, grief, fatigue, hypertension, headaches, insomnia, eczema and stress [42]. Loss of physical strength remains constant during a 6-month cohort and its effect is perceived more negatively in females than in men; carers' experiences should be looked at in both negative and positive ways, as these experiences change over time, and inter-and intra-individual patterns must be studied through different subgroups of carers [42].

4) Social effects a) Socio-economic problems
Nijboer et al. (2000), describing experiences of carers of patients with cancer over 6 months, reveals that lack of family support and financial problems remained constant over 6 months [15]. This is similar to findings of Sercekus et al.
(2014) qualitative study, which reports that participants experience social effects, self-esteem in male carers did not change over time but a less positive influence on self-esteem was reported by female carers and this could be due to differences in coping styles, emotional attentiveness and caring roles of women and men [15]. Pitceathly and Maguire (2003) identify that informal support has a positive effect on carers' coping styles [38]. a) Carers' need for support Mossin and Landmark (2011) report that support, a major factor that emerged from the study, is revealed when spouses voice a need to be supported by their sick husbands, family and the healthcare team, and this support plays a positive role in their experience [39]. Despite being sick, women felt a need to be supported as they were being supported at home, because that made them feel good and maintained their role and value [39]. Nonetheless, Kim and Carver (2007) suggest that gender role or orientation of carers' relationship to the partner plays

1) Complaints about healthcare personnel and hospital conditions
Patients and carers feel really discouraged and helpless when HCP caring for them go into disagreements and lack cooperation and proper communication; HCP must be open to second opinions outside consultation times for work to move smoothly [43]. Participants complain of problems that arise from the healthcare system such as: difficulties with small clinics in their residential area when they request referral to tertiary centres to continue receiving cancer treatment; long waiting times for treatment due to inadequate human resources; uncomfortable conditions of the hospital; and not enough equipment such as wheelchairs to ease patients' movement [42]. Kimberlin et al. (2004) reports that participants complain of time barriers such as waiting for appointment dates, excessive waiting before seeing HCP, waiting for telephone calls to be returned and inadequate time during meetings between patient and HCP, and these discouraged patients [43]. Participants complain that generally in hospital, needs of patients are regarded as more important than needs of carers, and this makes spouses think their own need to rest is not considered [39].
2) Involvement of the patient and carer in healthcare Kimberlin et al. (2004) recommend that information exchange be improved between HCP and couples dealing with cancer [43]. It highlights a need for greater recognition of patients as sources of information. The study was conducted through diaries, in which patients documented when pain medication was administered and side-effects, their questions and suggestions, and type of care which was helpful to them. This helped patients focus on their needs as they could not forget the type of questions to ask the doctor during review clinics. Kimberlin et al. (2004) suggest that information exchange between patients and healthcare workers enables active participation of patients and carers in care and the whole healthcare system, improving coordination of care and relationships among HCP, overcomes time barriers and addresses fears of pain medication use [43].

3) Education of patients and carers
Improving education of patients and carers is a dominant theme, as couples dealing with cancer express the need to understand the disease itself, its prognosis, signs and symptoms, pain medication choices, available treatment, treatment modalities, treatment side-effects and their management, care of the patient at  [43]. This is in line with Sercekus et al. (2014), which adds that patients and carers must be informed to ensure adherence of the patient to treatment prescribed and self-care activities [42]. All participants stress the importance of allowing them to participate in decision-making about care, ask questions and research their disease and available treatments, to enable them to have control over their illness and be part of the medical care [43]. comes and mediators, to determine the direct effect on carers' QOL and that of their patients [16]. The intensity of pain has a direct negative effect on the patient's QOL and not on the partner's QOL [16]. Kimberlin et al. (2004) suggests that a number of fears of use of pain medication emerged from interviews, including: fear of opioids, addiction, being judged, being seen as a weakling for admitting pain, loss of control and expressing need for medication [43]. These were largely expressed by patients. Carers expressed the fear of feeling that they are unable to manage pain anymore and of thinking that opioids actually hasten the patient's death.

5) Summary of theme 4
If HCP do not recognise the important role that female carers play for their patients and in the healthcare system, or their needs, then carers may feel intimidated. When female carers are actively involved in patient care, adequately informed about their patients' illness and treatment plan, and involved in decision-making, a good relationship develops between them and HCP and they become active members of the healthcare team.

Interpretation of the Results
The critical literature review explored and analysed challenges facing women caring for a spouse having cancer treatment. Key themes which emerged from the data include: "quality of marital relationship", "effective communication", "burdens related to caring" and "proper coordination of care among health care providers".

Theme 1: Quality of Marital Relationship
The quality of a marital relationship has a great influence on the way couples relate to each other when dealing with difficult situations like a cancer diagnosis and do not share patient information with carers [47].
The "patient focus" makes HCP not appreciate presence of the patient's close family near the patient, and sometimes these family members are constantly chased out of wards with the argument that the patient should receive total nursing care and be nursed in a quiet environment, because HCP regard carers as barriers to good care, which is actually very wrong, as patients themselves want to be around their loved ones, to receive moral support [5].

1) Masking feelings
Masking feelings are common in clinical practice as carers choose to "die inside" rather than talk openly with their patient or express their emotions openly with their patient; this causes a "conspiracy of silence" between a couple, where each is pretending to the other without talking or expressing their feelings.
Houldin (2007) [43]. Lack of or poor communication is evident in couples dealing with cancer because of the negative impact of the diagnosis on a couple and previous communications problems within a couple [57].
In clinical practice, there are instances where spouses ask HCP to withhold certain information from the patient, in an attempt to protect their patient, as they are afraid that when the patient knows the truth, they will be stressed and depressed; therefore, the spouse hears the information, keeps it and withholds it from the patient. Couple assessment must be included in healthcare especially for couples dealing with cancer, so that problems identified can be managed and couple interventions implemented accordingly.

3) Social effects
Cancer treatment is very involving; carers end up experiencing social problems such as role strain, quitting employment, financial difficulties, transport difficulties to and from hospital, isolation and restrictions in social life because of the increased care needs of the patient and increased care burden [40] [42]. Carers of cancer patients often experience disruptions to their social and domestic activities due to the burden of caring tasks [57]. Total disruption of daily life is evident in carers of cancer patients and it affects social aspects such as employment and financial difficulties [48].
In Cancer Diseases Hospital, Lusaka, almost all cancer patients and their carers undergo social problems, because of the location of the cancer hospital in the capital city of Zambia. Patients come from all over the country to access cancer treatment, and the treatment timeframe for treating cancer is generally long. On a positive note, the Government of Zambia pays for treatment for all Zambian citizens so that they can access free treatment. Therefore, patients and their carers just pay for transport to the cancer hospital, daily self-care, diagnostic services and food, because accommodation is free, unless one wants to benefit from high cost services which are charged. Due to expenses of food and diagnostic services, carers and patients tend to deplete resources until they do not even have transport money to go back to their home town. The social welfare unit then comes in to assist these families with transport money from hospital budgets for social welfare of cancer patients and their families. Social welfare, diagnosis and care services must be planned and put in place in hospital to ensure that cancer patients and their families are taken care of adequately.

4) Carers' coping mechanisms
Coping strategies used by carers include: turning to God, keeping busy with [43]. HCP do not recognise the role of carers of cancer patients, which is devastating to them [52]. Carers have many needs which are not identified and met by HCP [64].
2) Education and involvement of the patient and carer in healthcare Education and active involvement of patients and carers is important to enable them to be well informed to understand the disease, its prognosis, signs and symptoms, pain medication choices, available treatment, and treatment modalities, side-effects and management, as this enables them to be active and have control over their illness [42] [43]. Carers are often ignorant about the patient's cancer condition and if HCP have not taken time to educate them, they will not be able to identify and manage basic symptoms [64].
Some carers portray behaviours that indicate need to receive information from HCP so that they understand how to take care of their patients and relieve their uncertainty and anxiety about the disease; however, some carers do not show need to receive any information about their patient's illness as they are afraid of how they will react once they hear the bad news [66]. Support from HCP, family and friends positively influences carers [52].

3) Fear of use of pain medication
The intensity of pain has a direct negative effect on patients' QOL and not on partners' QOL [16] [43]. Patients' fears of the use of pain medication emerged from interviews and include: fear of opioids, addiction, being judged, being seen as a weakling for admitting pain, loss of control and expressing need for medication. Carers expressed fear of feeling unable to manage pain anymore and of thinking that opioids hasten the patient's death. cluded in the review was limited, and so relevant literature reviews were included; however, these tend to be vulnerable to reviewer biases [30]. The literature review was done independently by one researcher who was in training, and this meant that analysis by one independent individual was applied, and the study was not peer-reviewed by another researcher to achieve a balance. Effective analysis was achieved through use of a validated critical analysis tool. Constant supervision and guidance was sought from the research supervisor, creating an opportunity for questioning, challenging results, discussions and conclusions of the review [30].

Limitations of the Review
Notwithstanding these limitations, the results of the current review provide a worthwhile and exceptional understanding of challenges that spouses of cancer patients face when caring for their patients with cancer and these results add to the existing body of knowledge in this area.

Dissemination of Review Findings
The review findings added to the current body of knowledge and dissemination of the findings to HCP is vital. Therefore, review findings were distributed to clinicians and colleagues, through presentations in clinical meetings, conferences and workshops, and through this publication.

Recommendations for Future Research
The review highlighted the need to integrate female carers of cancer patients to the healthcare system by promptly recognizing their roles, needs and challenges.
More research is needed to find out more about effective support strategies that could improve female carers' QOL.

Conclusion
The first is quality of marital relationship, which states that female carers and their patients with cancer are directly affected by the cancer disease itself, symp-

Healthcare Clinical Implications
Female carers of cancer patients face several challenges, and this review creates a basis from which HCP will practise, to improve carers' QOL. HCP do not consider carers' role and needs; therefore, advocacy must be done to influence policy to integrate carers to the healthcare system. Policy guidelines should be put in place to guide HCP to care for not only patients but also their spouses. Challenges of carers of cancer patients must be promptly anticipated, identified and managed using the health care assessment system in clinical practice by HCP.
HCP should be educated to appreciate the value and role of female carers of cancer patients, their needs and how to support them. HCP must facilitate for carers and their patients to express feelings openly between each other. Carers must be helped to understand their role for patients and how they can support them. HCP must identify carers' support groups and create networks to support carers effectively. In conclusion, the challenges of female carers must be identified and managed, to enable their access to healthcare services. Care services for carers will improve their QOL and patients' QOL.

Operational Definitions
Spouse: partner or wife of someone in the civil state of marriage, or who has lived with a patient for over 3 months or has been acknowledged by the patient as his or her partner.
Breadwinner: the person in a household who earns most money and supports the family most.