Two wars on one front: Experiences of gynaecological cancer patients in the COVID-19 pandemic.

OBJECTIVE: The aim of this study is to explore the experiences of gynaecological cancer patients during the COVID-19 pandemic from their own perspectives.
METHODS: The study is a descriptive study with a qualitative design based on thematic analysis. We conducted the study with 17 women with gynaecological cancer and receiving chemotherapy in the Medical Oncology and Chemotherapy Unit of Kütahya Training and Research Hospital. The data were collected between April 2021 and May 2021 via an in-depth individual interview form. The COREQ checklist was followed in the study.
RESULTS: As a result of the interviews, we identified four main themes: the impacts of COVID-19 on life, the impact of COVID-19 on cancer treatment, the biggest fear during the COVID-19 pandemic and the metaphors of struggling with cancer during the COVID-19 pandemic.
CONCLUSION: The disruption of treatment services during the COVID-19 pandemic and women's fear of infection by the virus led to delays in cancer diagnosis and treatment. This situation caused the women's state of health to deteriorate, and the resultant regret and sadness that they experienced had an adverse effect on their mental health. Furthermore, women's self-isolation due to the fear of infection by the virus had a negative effect on their psychosocial health. Telehealth services should be provided for cancer patients to obtain accurate information and to easily access information about treatment processes during the pandemic, and telepsychological hotlines and peer support groups should be established to improve the psychosocial health of patients.

INTRODUCTION

From its first appearance in China in December 2019 to June 2021, COVID‐19 caused 183 million people to become sick and 4 million deaths worldwide (World Health Organization [WHO], 2021). In Turkey, 5,440,368 people became sick and 49,834 people died (TR Ministry of Health, 2021). Therefore, it was declared a pandemic by the WHO (2021).

The COVID‐19 pandemic has affected all areas of life such as education, the economy, health and social life (Tsamakis et al., 2020). Cancer patients have been particularly influenced by this period. While cancer patients are already fighting a traumatic war like cancer, they have to fight on a second front opened by the pandemic (Frey & Blank, 2020). In other words, the COVID‐19 pandemic has adversely affected the physical and psychological health, diagnosis and treatment processes of cancer patients (Tsamakis et al., 2020). In one study that was conducted, it was determined that the most important reasons for cancer patients' fears during the COVID‐19 pandemic were the delays in treatment and diagnosis, the cancellation of check‐up appointments and the risks associated with receiving chemotherapy (Moraliyage et al., 2021). Various studies have reported that cancer patients face many undesirable situations such as delays in diagnosis and treatment, change in appointment dates, decrease in appointment frequency and cancellation of surgeries due to disruption of health services during the pandemic (Schellekens & van der Lee, 2020; Wang et al., 2020). Some cancer patients have delayed or refused their chemotherapy (Schellekens & van der Lee, 2020) and have isolated themselves even from their closest relatives due to their vulnerability to infections and fear of COVID‐19 transmission (Schellekens & van der Lee, 2020; Wang et al., 2020). All of these have caused cancer to progress and metastasise, and the patients to experience psychosocial problems (anxiety, depression, post‐traumatic stress disorder, etc.) such as fear of being alone and dying, resulting in a low quality of life (Ciążyńska et al., 2020; Frey et al., 2020; Frey et al., 2021).

Although there are studies and expert opinions in the literature stating that cancer patients are at high risk of contracting COVID‐19, their symptoms are severe, and they may die, only limited studies have investigated the effect of COVID‐19 on the experiences of gynaecological cancer patients. The aim of this study is to explore the experiences of gynaecological cancer patients during the COVID‐19 pandemic from their own perspectives.

METHODS

Study design

In this study, a descriptive qualitative design with single interviews, one of the qualitative research methods, was used (Denzin, 2018). The descriptive case study is a multifaceted, systematic and in‐depth research method that examines a case that occurs in real life (Creswell & Creswell, 2017). The metaphor approach was used to explain women's experiences of struggling with cancer in the pandemic. Metaphors allow the unknown to be explained with known experiences and the whole story with a single symbol (Weldon et al., 2013). The ‘Consolidated Criteria for Reporting Qualitative Research’ (COREQ) checklist was employed to ensure comprehensive reporting throughout this study (Tong et al., 2007).

Setting and participants

The population consisted of women with gynaecological cancer who were receiving chemotherapy and volunteered to participate in the study in the Medical Oncology and Chemotherapy Unit of Kütahya Training and Research Hospital. The purposive sampling method employed in qualitative research was used in the study (Marshall & Rossman, 2014). The inclusion criteria of this study were being 18 years of age or older, knowing the diagnosis, knowing Turkish and volunteering to participate in the study (Table 1). In qualitative research, the sample size is calculated according to the saturation point. The saturation point is reached when the interviewer starts to hear the same comments again and again or when no new information emerges (Morse, 2015). The data in this study reached saturation point with 17 participants (Table 1).

TABLE 1

Socio‐demographic characteristics of the participants

Participant ID	Age	Education level	Diagnosis	Time elapsed since diagnosis	Family history of cancer	Social support status	COVID‐19‐related death in the immediate circle
1	54	High school	Over	2.5 months	No	Yes	No
2	45	High school	Over	1 year	Yes	Yes	No
3	59	Bachelor's degree	Over	3 months	No	Yes	No
4	52	Bachelor's degree	Endometrium	2 years	Yes	Yes	No
5	47	Bachelor's degree	Over	3 months	Yes	Yes	No
6	43	Primary school	Over	2 months	Yes	Yes	No
7	50	Primary school	Over	6 months	Yes	Yes	Yes
8	41	Primary school	Over	6 months	Yes	Yes	Yes
9	49	Primary school	Over	1 year	Yes	Yes	No
10	58	Primary school	Cervix	1 year	No	Yes	No
11	62	Primary school	Over	9 months	No	Yes	No
12	60	Literate	Endometrium	8 years	Yes	Yes	Yes
13	55	High school	Over	3 years	No	Yes	No
14	52	Primary school	Endometrium	5 months	Yes	Yes	Yes
15	42	Bachelor's degree	Over	2 months	Yes	Yes	No
16	63	High school	Cervix	4 months	Yes	Yes	Yes
17	35	High school	Cervix	1 year	No	Yes	No

Data collection

The data were collected between April 2021 and May 2021 using the descriptive information form prepared by the authors and a semi‐structured in‐depth interview form. The descriptive information form consists of seven questions, including socio‐demographic characteristics and disease information of the women in the study. The semi‐structured interview form consists of four questions. Interviews were conducted by the author (F. S. B.), a female women's health and diseases nurse.

Interviews were conducted in the intervention room in the chemotherapy unit using voice recording. All necessary preparations were made before the interviews. After the implementation of the descriptive information form, all women were asked the following opening question to start the interviews: ‘How has the COVID‐19 pandemic affected your life? Could you please share your experiences with me?’. Sub‐questions were also used to allow and encourage women to explain their experiences.

The main research questions are as follows:

‘How has the COVID‐19 pandemic affected your life? Could you please share your experiences with me?’

‘How has the COVID‐19 pandemic affected your cancer treatment? Could you please share your experiences with me?’

‘What is your biggest fear during the COVID‐19 pandemic?’

‘If you could compare fighting cancer in the COVID‐19 pandemic to something, what would it be and why?’

Data analysis

Thematic analysis is one of the qualitative analysis methods that enable the data set to be organised and explained in detail (Vaismoradi et al., 2013). In this study, interviews were conducted based on the thematic analysis approach of Clarke and Braun (2014). Firstly, the interviews were read several times to become familiar with the data and to understand in depth the experiences of the gynaecological cancer patients. In the second stage, starting codes were assigned to the data in order to define the content of the interviews. Thirdly, sub‐themes were created by examining the codes. In the fourth stage, the appropriateness of the themes for the codes and the women's statements was examined. In the fifth stage, the themes were defined and named. In the last stage, the gynaecological cancer patients' experiences in the COVID‐19 pandemic were reported. In this study, interviews were transcribed verbatim, and all these steps were followed in the analysis independently by two authors (R. A. and F. S. B.), both of whom are educators in nursing science. The first and third authors have published studies on cancer and qualitative research. The participants and the authors of the study have the same mother tongue. After the analysis, the appropriateness of the themes was checked by two external experts.

Trustworthiness

In this study, the following was done to ensure trustworthiness (Holloway & Galvin, 2016; Noble & Smith, 2015): The in‐depth interview form was evaluated by two experts for confirmability. The audio recordings of the interviews were transcribed verbatim. The purposive sampling method was used for transferability. For dependability, two authors analysed the data independently. During the coding process, the authors exchanged ideas about the appropriateness of the codes obtained from the data repeated more than once. For credibility, the relationship between the main and sub‐themes was checked. Finally, the final theming and sub‐theming were evaluated by two experts for confirmability.

Ethical consideration

Ethical approval for the study was granted by the Republic of Turkey Ministry of Health COVID‐19 Research Assessment Commission, and the university's ethics committee approval and institutional permission were obtained (approval code: 2021/07‐10). The women who agreed to participate in the study were informed about the purpose of the study, how it would be conducted, that an audio recording would be made and that they could withdraw from the study whenever they wanted, and their written and verbal consent was obtained.

RESULTS

The experiences of women with gynaecological cancer during the COVID‐19 pandemic were examined under four main themes and nine sub‐themes: the impacts of COVID‐19 on life, the impact of COVID‐19 on cancer treatment, the biggest fear during the COVID‐19 pandemic and the metaphors of struggling with cancer during the COVID‐19 pandemic (Table 2).

TABLE 2

Main themes and sub‐themes

Main themes	Sub‐themes
The impacts of COVID‐19 on life	‐ Disruption in social life
	‐ Change in social life
	‐ Delay in getting a cancer diagnosis
The impact of COVID‐19 on cancer treatment	‐ Reduction in appointment frequency
	‐ Disruption in treatment services
	‐ Preferring a health centre that they find safe
The biggest fear during the COVID‐19 pandemic	‐ Fear of recurrence
	‐ Dying without a funeral
	‐ Needing care
The metaphors of struggling with cancer during the COVID‐19 pandemic	—

Main theme: The impacts of COVID‐19 on life

The impacts of the COVID‐19 pandemic on the life of women with gynaecological cancer were examined under three sub‐themes: disruption in social life, change in social life and delay in getting a cancer diagnosis.

Disruption in social life

Most of the women (n = 9) stated that in addition to having cancer, the fear of COVID‐19 transmission caused disruptions in their social lives, they had to stay at home, and they missed kissing, hugging and touching each other:

I have cancer, and we are at greater risk … At first, I was very scared, I was at home all the time, and still, I am … I have not got sick yet, thank God. But believe me, I have not even been for a walk … My closest friend died, I did not go to the funeral, I just talked on the phone …. ( W1)

I did not go anywhere but my mother's house … Previously, my means of communication were touching and hugging, which I used in my social life. During the pandemic, they are completely over … I can say that my social life is over. ( W4)

Due to the sensitivity of being a cancer patient and the fear of contracting COVID‐19, women expressed the sadness of not being able to use their old social communication tools as follows:

… I miss hugging the people I love. Now that I have chemotherapy, and there is a pandemic, I cannot even hug my children the way I like … This makes me sad. Being diagnosed with cancer during this period also limits my social life. If it were not for corona, maybe those in my social circle would visit me, I would have the chance to participate in an activity …. ( W5)

It ruined, it ruined everything, there is no such thing as social life anymore … I miss hugging and touching such a person so much …. ( W2)

Change in social life

Some women (n = 3) stated that they changed their social life by moving to the village, plateau or summer house because of the risk of virus transmission in the family or the crowd in the city:

We moved to the house in the village in the corona … We have a motorbike in the village, my husband takes me for a ride. While he is doing something, I sit in the shade and get some fresh air …. ( W12)

My husband took me to the valley because our children go to work and may carry the viruses. We have everything in the valley … Children have already had COVID. I live in the valley now. I only go to the city for treatment. ( W11)

Delay in getting a cancer diagnosis

Some women stated that although they noticed some cancer symptoms, they postponed the examination due to the fear ofCOVID‐19 transmission, and they expressed their sadness as follows:

Actually, I had many symptoms of cancer … I delayed it as much as possible because of COVID. I even drank herbal tea, thinking it was a problem with my stomach … I am so angry with myself …. ( W3)

I used to bleed from time to time. Even though I'm menopausal, I was worried that I was bleeding. But I postponed it so that I could go when COVID is over and here is the result. I wish I had come earlier …. ( W16)

Impact of COVID‐19 on cancer treatment

The impact of COVID‐19 on cancer treatment theme was examined under three sub‐themes: decrease in the frequency of appointments, disruption in treatment services and preferring the health centre that they found safer.

Reduction in appointment frequency

Most of the women noted that there was a decrease in the frequency of appointments to reduce the risk of COVID transmission during the pandemic:

As the number of cases is high, the frequency of our appointments is not the same as before. Normally we had monthly and quarterly check‐ups. Our monthly checks have been canceled in the last 2 years. ( W2)

I normally take a small amount of medication weekly so as to have fewer chemotherapy side effects. In this period, I started to receive monthly medications due to the virus …. ( W16)

Disruption in treatment services

Most of the women reported that their treatment was disrupted due to the pandemic and that their condition got worse, and consequently, their psychology was adversely affected:

After the diagnosis, we found a gynecologic oncologist, but I could not get an appointment. We searched, but we could not find a suitable day. The surgery was delayed; an appointment was made for a very late date …. ( W5)

The day they took a smear from me, the whole hospital was evacuated because of the virus. I did not understand what happened. They called me six months later. The tumor had already spread to the liver. 6 months ago, there was no spread. If they had not kept me waiting for six months, my situation would not be this bad now. ( W9)

The statement of a woman whose treatment was disrupted and who could not reach her doctor whenever she wanted is as follows:

I could not get any help from the hospital. My treatments have been delayed, and the dates have changed constantly … It is so bad that you are a cancer patient and cannot reach the doctor when you want … The pandemic has affected my treatment, my life, and my psychology a lot. ( W4)

Preferring a health centre that they found safer

Some of the women stated that they preferred the private hospital, which they found safer than the public hospital, because of the hygiene and the fear of virus transmission:

Because of the pandemic, I wanted to get my treatment in a private hospital because the number of patients is fewer, it is cleaner, and the risk of the virus is low, and I took out a loan of 95 thousand Turkish liras. I saw public hospitals, it's very bad, there are too many cases …. ( W17)

Main theme: The biggest fear in the COVID‐19 pandemic

The biggest fears of women during the pandemic period were examined under three sub‐themes: fear of recurrence, dying without a funeral and needing care.

Fear of recurrence

Most of the women expressed that they were afraid of the interruption of the treatment and the related recurrence during the pandemic period:

… I am afraid that if my surgery is canceled during the pandemic, cancer will spread to different organs. I am afraid, especially now that I am waiting for the surgery. I am afraid that if the time is prolonged, the disease will progress. ( W8)

At the moment, there is COVID, the treatment may be delayed, and it is difficult to meet with the doctor. The metastasis of cancer scares me a lot … I would like to go to all my check‐ups and be treated on time. The development of cancer caused by the pandemic really scares me. ( W11)

Dying without a funeral

Most of the women stated that they were afraid of dying with the diagnosis of COVID‐19 and being buried without a funeral:

Experiencing COVID‐19 has been very bad … Everyone is getting the disease now. I'm afraid that I will get COVID too and will be buried without anyone by my side. God save us. ( W1)

Because there is this COVID scourge, funerals are not held. How can something like this happen? People are buried like orphans. What a bad situation! This is my biggest fear …. ( W14)

Needing care

Some women emphasised that they were not afraid of COVID or other diseases, they trusted in God and they were only afraid of needing care. The statements of some of the women are as follows:

When the time comes, it happens, I want to reach reunion time before being bed‐ridden, without needing anyone. I do not fear anything but God … I trust in God. But I am afraid of needing care. ( W13)

I am not afraid at all, my daughter, why should I be afraid, there is God. Whatever God wants, it happens. I do not want to put fear into my heart. I'm just afraid that in the end, maybe I will need my children. ( W12)

Main theme: Metaphors for struggling with cancer in the COVID‐19 pandemic

The women created nine metaphors about struggling with cancer in the COVID‐19 pandemic. The first three metaphors mentioned the most were war, test and octopus (Table 3).

TABLE 3

Metaphors for struggling cancer in the COVID‐19 pandemic

Metaphor	Code	Justification
Unarmed war	W1, W16, W17	‘There are two roads ahead of you, both are bad … Both end in death. So they are both an unarmed war …’
		‘Unarmed war. Two great enemies and there is nothing you can do …’
War	W5, W8, W7, W10	‘… it is like a war of two powerful countries, but of course, I am the one left in the middle.’
		‘I have two battles right now. What can I say, very difficult …’
		‘The war … I hope we will win together with Allah Almighty.’
Marathon	W2	‘There are two people I fight, there are two people I compete with. And if one side wins it means bad. It's a marathon. You will run tirelessly. You will run without giving up.’
Octopus	W3, W4	‘Like an octopus. It comes towards me with all its arms. The problems in front of me are like my octopus. They attack from every arm. I feel stuck.’
		‘… If I had to think about it … I am wrapped all around, but at the same time I am so stuck like an octopus …’
Test	W6, W11, W12	‘I think it's like two big tests, it really affected me. But whatever God says happens.’
		‘It's like two exams. It's God's test, but I think it'll beat me if I get caught …’
		‘How will God come to our minds if God does not test us? If we do not have such troubles, how will we return to Allah?’
Devastation	W9	‘Fighting against the two is, of course, like destruction, greater destruction. I cannot see my friends, and I have to face everything myself.’
Slime	W13	‘As if I've fallen into a slime lake, the higher I want to go, the more they pull me in …’
Sea voyage	W14	‘An endless sea journey … there is also the wind, and it shakes you from every direction.’
Slide	W15	‘There is a long pipe slide in playgrounds. Well, there is me in the middle of it, there is cancer at one end and covid at the other. Wherever I go, the other barks …’

DISCUSSION

The pandemic period has created a crisis in all areas of life and deeply affected the health system. The transmission rate of the virus has caused the transfer of physical infrastructure and health resources to this area and the disruption of existing treatment processes, which has led to delays in treatment and stress, especially for oncology patients (Frey & Blank, 2020). The aim of this study is to explore the experiences of gynaecological cancer patients during the COVID‐19 pandemic from their own perspectives. The experiences of women with gynaecological cancer during the COVID‐19 pandemic were analysed under four main themes: the impacts of COVID‐19 on life, the impact of COVID‐19 on cancer treatment, the biggest fear during the COVID‐19 pandemic and the metaphors of struggling with cancer during the COVID‐19 pandemic.

Cancer patients are more vulnerable to infections due to the suppression of the immune system by cancer treatment. This situation causes patients to isolate themselves, even from their families, due to the fear of COVID‐19 transmission, and to experience fear and stress (Liang et al., 2020; Wang et al., 2020). The patients in this study reported that they did not even go for a walk due to the fear of COVID‐19, that they did not kiss or hug their children and spouses and that they missed being able to do so very much. Patients also stated that they made changes in their social lives to maintain their lives in villages and plateaus, where they felt safe. In a qualitative study conducted with cancer patients, one patient expressed how self‐isolation made him or her feel sad and lonely: ‘As an elderly person living alone with cancer, this is a period that makes me feel much more alone … My skin longs to be touched and cuddled. But no hugs …’ (Schellekens & van der Lee, 2020). A study conducted by Ciążyńska et al. (2020) on cancer patients who were treated during the pandemic period showed that the general cognitive and social functions of individuals were adversely affected and that the quality of life of patients living alone decreased. While being isolated from the social environment made people experience depressive symptoms, going to the hospital also increases the risk of transmission and puts individuals in a deep dilemma (Wang et al., 2020). The UK National Health Service (NHS) data showed that 45% of individuals with potential cancer symptoms did not visit the hospital for fear of the virus and that 350,000 fewer cases were detected compared to the previous period of the same year (The Lancet Oncology, 2021). In this study, although some women experienced possible cancer symptoms, they avoided going to the hospital, sought alternative solutions for the symptoms and experienced sadness and regret due to delaying the cancer diagnosis. In a study on the general population in India, failure to detect women with cervical cancer at an early stage (Stage I and Stage II) during the COVID‐19 epidemic caused 68–77% of women to die (Gupta et al., 2021). Consistent with our findings, in the systematic analysis of 64 studies with cancer patients during the pandemic period by Riera et al. (2021), it was seen that the diagnosis of patients was delayed (Riera et al., 2021).

The uncertainty of the new treatment protocols formed during the pandemic has caused delays and disruptions in patient care and treatment. Cancer patients have become a disadvantaged group due to the rapid progression of the disease (Ramirez et al., 2020; Sokas et al., 2021). In this study, women experienced a decrease in the frequency of appointments, disruption or delay in their treatment, and related sadness and anger with the increase in COVID‐19 cases. Frey et al. (2020) conducted a study with women with ovarian cancer and similarly reported that 33% of the patients were delayed in their treatment and that 26.3% of these delays were due to doctor appointments and 15.1% were due to laboratory tests. Chen et al. (2021), in their study conducted with women receiving gynaecological cancer treatment, found that while the treatment of 93% of the women was delayed by the medical team, 7% of the women preferred to postpone it themselves. As a result of the same study, it was determined that 36% of the women had their clinical appointments cancelled, 15% had their diagnosis and imaging appointments cancelled and 16% had their laboratory tests cancelled (Chen et al., 2021). In another study on the experiences of gynaecological cancer patients, one of the women expressed her disappointment at the postponement of her treatment as follows: ‘… I had to wait until March 10 for the surgery. So it was a bit of a long wait. Actually I was hoping it would happen one week before …’ (Moran et al., 2020). The same study also revealed that patients preferred private health centres, which they found safer, despite the risk of experiencing economic problems, because of the fear of the virus caused by patient density in the health centres. The studies conducted with pregnant women during the pandemic period emphasised that women preferred hospitals that they found safer due to the cancellation of their appointments at the state hospital and the fear of infection, which is in parallel with our study findings (Aydin & Aktaş, 2021; Mizrak Sahin & Kabakci, 2021).

Being diagnosed with cancer during the pandemic has resulted in struggling against two enemies on one front: the COVID‐19 virus and cancer. Pandemic cancer patients have difficulties in accessing treatment, suffer a decrease in support from family and social life, and experience the fear of virus infection, resulting in their experiencing many fears and a negatively affected psychology (Liu et al., 2020). In this study, the biggest fear women experienced during the pandemic was found to be the fear of recurrence due to the cancellation of appointments and surgical operations. In a study conducted by Gultekin et al. (2021) with gynaecological cancer patients in 16 European countries, it was found that 71% of women feared cancer recurrence if their treatment was interrupted or cancelled. Similar results were found in a study examining the impact of the pandemic on women with breast cancer (Kim & Kim, 2021). In this current study, women reported feeling afraid of being buried without a funeral and being sent to die alone due to COVID‐19 restrictions. Schellekens and van der Lee (2020) noted that cancer patients were afraid of dying alone before they could say goodbye to their relatives. However, in this study, what women were afraid of was needing care. In a study on the experiences of geriatric oncology patients, a woman who spoke to her doctor expressed her sadness about needing care as follows: ‘I don't want to be a burden to my family and my daughter anymore. Can you help me end my suffering?’ (Delgado‐Guay et al., 2013).

Metaphors allow abstract thoughts to be associated with experiences and clarified (Potts & Semino, 2019). In this study, all the metaphors used by women consist of negative concepts, and women mostly defined being a cancer patient during the COVID‐19 period using the metaphors of war, unarmed war, octopus, test and devastation. Women stated that they were already in a war and that another front was added to it, while they were stuck in the middle. Some compared this situation to an octopus attacking them with many arms. In a study by Körükcü (2018) with gynaecological cancer patients in Turkey, women compared cancer mostly to war and Azrael. The literature cites that the most commonly used metaphors about cancer by patients are war, conflict and journey (Hommerberg et al., 2020; Woodgate & Busolo, 2017). The COVID‐19 pandemic has revived war metaphors. Many political leaders have made statements such as ‘We are in a war’ and have stated that the pandemic has been an enemy since the beginning (Semino, 2021).

CONCLUSION

The study shows that the disruption of treatment services during the COVID‐19 pandemic and women's fear of infection by the virus led to delays in cancer diagnosis and treatment. This situation negatively affected women's mental health due to the progression of their cancer and the regret and sadness they experienced in association with this. In addition, the fact that women isolated themselves even from their families due to their fear of contracting the virus, were unable to hug and kiss as before, experienced a fear of relapse due to disruptions in their treatment and were afraid of dying from COVID‐19 without a funeral had an adverse effect on their psychosocial health.

IMPLICATIONS FOR PRACTICE

The pandemic period has once again drawn attention to the importance of psycho‐oncological care. For patients to get through this difficult period more easily, they should be provided with telehealth and telenursing consultancy services, and their biopsychosocial health should be promoted. Telehealth services should be 24/7, should provide access/direct individuals to timely and accurate information sources and should be free of charge. Peer support groups should be formed to enable individuals to benefit from peer experiences. It is recommended that nurses make arrangements to enhance women's physical and emotional health and improve access to care in order to reduce the trauma women are exposed to in this war, which they are fighting on two fronts.

CONFLICT OF INTERESTS

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.