Health-related quality of life in dialysis patients Namdar A1, Beigizadeh Sh2, Najafipour S*3,4 Received: 09/13/2011

Revised: 02/14/2012

Accepted: 05/24/2012

1. Dept. of Community Medicine, School of Medicine, Jahrom University of Medical Sciences, Jahrom, Iran 2. Dept. of Biostatistics, Jahrom University of Medical Sciences, Jahrom, Iran 4. Center for Studies on Medical Education Development, Jahrom University of Medical Sciences, Jahrom, Iran 3. Dept. of Medical Education, School of Medicine, Jahrom University of Medical Sciences, Jahrom, Iran Journal of Jahrom University of Medical Sciences, Vol. 10, No. 4, Winter 2013

Abstract

J Jahrom Univ Med Sci 2013; 10(4):16-24

Introduction: Measuring the quality of life in chronic diseases such as end stage renal disease (ESRD) today is considered as a favorite standard in the medical world. This study was conducted aiming at determining health- related quality of life in dialysis patients in Jahrom. Materials and Methods: This is a cross-sectional descriptive study conducted on 52 patients under hemodialysis treatment referred to dialysis center in Motahari hospital of Jahrom city in the year 2010. Data were collected using a questionnaire including 2 parts: demographic variables and SF36. Descriptive and analytical statistics (Mean and Standard Deviation, in-depent t-test,One-Way ANOVA) were used to analyze the data in SPSS-15. Probability values less than 0.05 were considered as significant. Result: The results showed that the mean age of the study group was 56.48± 15.38. 46.2% were female and 53.8% male. The mean score of the quality of life (QOL) of the study patients was 50.38±15.80. The The lowest scores were recorded for physical functioning (37.49±27.90) and the the highest scores belonged to mental health (61.51±19.52). The results showed a significant difference between the mean of QOL and independent variables of age, marriage, and sex. (P=.026, P=.012, P=.001). There was no significant difference between the mean of QOL and family income, educational level, background diseases, number of children, and duration of dialysis treatment. Conclusion: The results showed large variations in the dimensions of life in end stage renal disease as the result of hemodialysis. , Family and health care team members can use factors influencing the patients’ quality of life in order to provide care and support programs for patients to help them cope with the illness and improve their quality of life. Keywords: Quality of Life, Renal Dialysis, Deficiency, Kidney Diseases

Introduction One of the major public health problems is chronic kidney disease (1). Chronic renal

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failure is a disease with severe and irreversible renal dysfunction, leading to inability of the body to maintain the balance of fluid, electrolyte, and

* Corresponding author, Address: Dept. of Medical Education, School of Medicine, Hemmat Campus, Hemmat Highway, Tehran University of Medical Sciences, Tehran, Iran Tel: +98 917 7130261 Email: [email protected]

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metabolism (2). Hemodialysis is a treatment to improve patients with chronic renal failure. Annually, over 60000 people lose their lives around the world due to renal failure (3). In the United States of America alone, nearly 300000 people suffer from this disease. The annual incidence of this disease is approximately 242 cases per one million people, and 8% is added to this number each year (4). According to the statistics in Iran, each year 1200-1600 people (3) are added to the patients with this disease and the number of patients undergoing hemodialysis is increased by nearly 15% (5). Based on the 2007 report by the Renal Failure and Kidney Transplantation Research Center in Iran, 29000 people have renal failure and 14000 of them underwent hemodialysis. Currently, there are 15000 people with chronic kidney failure in Tehran, of whom, 3700 people undergo hemodialysis (6). Today, because of the epidemiological changes of acute diseases to chronic ones, the criterion of quantity of life based on mortality rate is no longer applicable, and the new qualitative criterion, which assesses the effect of the disease and treatment interventions on patients’ daily life, has been considered as a replacement (7). Measuring the quality of life in patients with chronic diseases like renal failure, is a subject of interest to the world of medicine. The World Health Organization defines quality of life as the person’s understanding and concept of his own life conditions within the culture and values of the society in terms of individual’s goals, expectations, standards, and interests (8). Although there is still no consensus on the definition of quality of life, most experts consider it as a multidimensional concept that involves physical aspects, disease signs and the effects of treatment on life, psycho-social status, family and finances (9). By creating physical, social, economic etc., disorders, diseases can cause patient’s reassessment of his own health condition and quality of life. These disorders include

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damages due to kidney disease, which can lead to numerous problems, leaving a chronic and progressive impact on cardiovascular and other organs (4). Although hemodialysis has raised hope in patients with chronic renal failure, due to potential complications, it may have several problems for the patient including hypotension, muscle cramps, hemorrhage, air embolism, chest pain, dialysis imbalance, consciousness disturbances, and seizures (8). Therefore, in assessment of quality of life, any change should be regarded serious. Quality of life is a powerful force in guidance, preservation and promotion of health in various societies and cultures (10). It is believed that people’s quality of life is an important criterion for efficient health care, and helps predict events of disability and deaths. Assessment of quality of life helps fundamental consideration of patients’ problems (11). Also, evaluation of quality of life helps planning health care and support programs for these patients, and can identify predictors of sense of wellbeing (12). Incidence of chronic renal failure and its hemodialysis treatment lead to changes in lifestyle, health status, and the person’s role, all of which affect his quality of life in some way (3). Cattner quoting Ting states that one of the reasons for starting hemodialysis in patients with chronic kidney failure is enhancing feeling good factor in these patients (13). Although studies have been carried out on the quality of life in patients with chronic renal disease, none have been conducted on this subject in Jahrom City so far. Furthermore, considering that planning for enhancement of health of these patients requires sufficient information on various aspects of their quality of life, and that the results of studies conducted in other regions, due to social and cultural differences cannot be much applicable, thus, the present study was conducted with the aim to assess quality of life in these patients in Jahrom. By describing how individual and social characteristics impact

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Health-related quality of life in dialysis

quality of life, and by considering more disease-affected aspects of quality of life that require planning, practical steps can be taken in order to improve quality of life of these patients. Materials and Methods The present study is a descriptive-sectional study. The study population was selected by census from all 60 patients with chronic kidney failure undergoing hemodialysis by attending hemodialysis center at Shahid Motahari teaching hospital in Jahrom from Dec 2010 to Jan 2011. Fifty-two patients met the study inclusion criteria (over 18 years of age, hemodialysis for minimum of 2 months, desire to take part, no disease requiring hospitalization) and took part in the study. Exclusion criteria were having known psychiatric disorder, being hospitalized for any reason, and lack of intention to take part and not answering the questions of the questionnaire. Data collection was carried out by means of a questionnaire in two parts; part one contained demographic data and disease parameters such as age, gender, education, occupation, income, place of residence, marital status, number of children, duration of illness, duration of treatment by hemodialysis, frequency of dialysis per week, and underlying illnesses, and part two of the questionnaire included short form of SF-36. This questionnaire was designed by Vaar et al. in U.S. for measuring quality of life of healthy and ill people (14). Validity and reliability of the Persian version was confirmed by Montazeri et al. in a study on people of Tehran (15). The SF-36 contains 36 items with 8 health-related sub-scales that measure two physical and mental component summaries. The physical component summary (PCS) includes dimensions of physical functioning, role limitations due to physical health problems, bodily pain and general health, and mental component summary (MCS) includes dimensions of role limitation due to emotional problems, vitality, social

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functioning and mental health. Questions are rated according to the RAND scoring system from 0-100, and the score for a scale can be found by summing up scores of each sub-scale and dividing it by the number of questions in that sub-scale. Higher scores in each sub-scale indicate a more favorable condition. Finally, scores of these 8 sub-scales are summarized into two components of physical (physical health) and mental (mental health). Data were collected after necessary explanations and readiness of participants to answer the questions in an interview with the researcher. Data were analyzed by SPSS15 software using descriptive and inferential statistics (mean, standard deviation, one-way ANOVA, and t-test) with significance level at 0.05. Results In this descriptive-sectional study, 52 patients (qualified to take part in the study) undergoing hemodialysis at Shahid Motahari teaching hospital in Jahrom participated. Table 1 presents demographic details of the patients. Patients’ age ranged 22-86 years with mean age of 56.48±15.38, 24 (46.2%) patients were females and the rest males, 65.4% were married, and majority (65.4%) of patients were illiterate, 57.7% were city dwellers, 96.2% were unemployed, 57.7% were of poor economic status. Duration of treatment of these patients was 2-132 months, with mean duration of 32.69±27.33 months. Fifteen patients (28.9%) stated that their health had worsened since last year, and 24 women (46.2%) described their health as average. Mean total score of quality of life of patients was 50.38±15.8. In the 8 dimensions of quality of life, physical functioning scored the lowest (37.94±27.9), and role limitation due to physical problems scored (40.87±28.01). Next, mean mental health scored the highest with (61.51±19.52) (table 2). According to the results of this study, men scored higher than women in all 8

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Health-related quality of life in dialysis

dimensions of quality of life. In men and women, the best condition related to mental health, and the worst to physical functioning. Between men and women, there was a significant difference in mean physical functioning, PCS, and mean overall core of quality of life (P=0.002, P=0.02, P=0.026). Also, the difference between men and women in mean physical pain, general health, and vitality was significant (P=0.047, P=0.001, P=0.042). In other dimensions of quality of life, there was no significant difference between men and women (table 3). There was a significant difference among different age groups in the overall quality of life score and PCS, and also between physical functioning and role limitation due to physical problems (P=0.002, P=0.012, P=0.002,P=0.015). But there was no significant difference in other dimensions (table 1). There was a significant difference in marital status between mean overall score of quality of life and marital status, and between PCS and its dimensions (physical functioning, role limitation due to physical problems, physical pain, and general health) (P=0.002, P=0.026, P=0.001, P=0.001, P=0.001). But no significant difference was observed in other dimensions of quality of life (Table 1). According to the results obtained, in terms of economic status, those with higher incomes had better quality of life. In other words, mean overall quality of life score of patients with higher incomes was nearly 25 points more than low-income patients, but this difference was insignificant, probably because of the low number of high-income patients (5.8%). However, this difference was significant in PCS and then, in role limitation due to physical health problems (P=0.023, P=0.034) (table 1). Quality of life was better among the more educated, and patients with university education scored the highest, but no significant difference was observed between quality of life and education level.

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There was a significant difference between role limitation due to physical health problems and mean mental health and education level of the spouse (P=0.013, P=0.036). However, this difference was insignificant in other dimensions (table 1). The employed, compared to the unemployed, scored higher in all 8 dimensions of quality of life, but the difference was insignificant (table1). Patients with underlying diseases such as hypertension, diabetes, cardiovascular, or a combination of these had lower quality of life, and the worst condition in all dimensions of quality of life related to patients with all three diseases: hypertension, diabetes and cardiovascular. There was a significant difference between mean physical functioning and mean mental health with underlying diseases (P=0.039, P=0.034). But, in other dimensions, the difference was insignificant. There was no significant difference between score of quality of life in the 8 dimensions and component summary with number of children, duration of dialysis, and frequency of dialysis per week (table 1). Also, no significant difference was found between dimensions of quality of life and also, component summary with place of residence or insurance status. Discussion Quality of life is considered an indicator of quality of health care and a part of disease control plans. In this study, mean overall score of quality of life was found to be in the average range, which was consistent with the description of majority of patients of their general health, and also with the results of a study by Vosooghi. However, it disagreed with results of some studies that reported quality of life of hemodialysis patients satisfactory, and also with Harirchi’s study that reported quality of life of these patients as bad (16-18, 12).

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Health-related quality of life in dialysis

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Table 1- Frequency distribution of demographic parameters and their relationship with quality of life of patients undergoing dialysis (N=52) Variable

Significant

Gender

Age group

Marital status Quality of life

Education level

Economic status

Number of children

Current occupation Frequency of dialysis per week

Duration of treatment with dialysis

Female Male 22-32 33-42 43-52 53-62 63-72 >73 Single Married Widow Illiterate Elementary High school University No income Under 2000000 Rials 2000000-5000000 Rials Over 5000000 Rials 0 1-3 4-6 >7 Employed Unemployed Once Twice Thrice 4 times Under 2 years 2-4 years 4-6 years More than 6 years

Number

%

Mean±SD

28 24 6 3 9 12 17 5 5 34 13 34 7 7 4 14

53.8 46.2 11.5 5.7 17.3 23.07 32.7 9.6 9.6 65.4 25.0 65.4 13.5 13.5 7.0 26.9

45.27±12.60 54.77±17.13 65.16±5.37 46.71±21.87 58.52±18.59 51.61±13.08 41.35±14.40 47.96±8.61 65.37±5.9 52.55±15.90 38.94±10.28 47.91±14.68 50.77±19.62 54.19±18.97 64.07±88.79 45.07±9.51

16

30.8

53.29±13.89

19

36.5

48.73±19.57

3

5.8

70.13±3.60

1 10 16 17 2 50 10 26 15 1 23 17 9 3

2.3 22.7 36.4 38.6 3.8 96.2 19.2 50.0 28.8 1.9 44.3 32.7 17.3 5.8

46.0±0.0 53.46±17.41 51.39±18.44 42.94±11.94 67.32±6.26 49.71±15.72 49.98±14.32 48.06±14.77 52.26±18.60 62.89±0.0 49.98±14.32 48.06±14.77 52.26±18.60 62.89±0.0

Table 2- Mean score of patients undergoing dialysis in dimensions of SF-36 Quality of life dimensions

Minimum

Maximum

Mean

Physical functioning Role limitation due to physical health problems Bodily pain Role limitation due to emotional problems General health Vitality Social functioning Mental health Physical component summary Mental component summary Overall score of quality of life

0

90

37.94

Standard deviation 27.90

0

100

40.87

28.01

10

90

51.15

24.78

0

100

58.33

32.25

20 5 12.5 16 12.5 21.1 20.08

95 95 100 100 81.2 100 86.94

50.35 52.28 54.16 61.51 44.92 57.24 50.38

17.01 18.69 23.53 19.52 18.15 18.51 15.80

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level 0.029*

0.01*

0.001*

0.239

0.067

0.321

0.100

0.724

0.724

Health-related quality of life in dialysis

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Table 3- Mean score of dimensions of quality of life of patients undergoing dialysis in terms of gender Dimensions of quality of life Physical functioning

Gender

Physical role Physical pain Emotional role General health Vitality Social functioning Mental health Physical component summary Mental component summary Overall score of quality of life

Mean

Male Female

Num ber 27 24

45.0 30.0

Standard deviation 28.28 25.91

Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female

28 24 28 24 28 24 24 24 22 24 24 24 22 23 28 24 28 24 28 24

49.11 31.25 57.50 43.75 59.52 56.94 58.16 42.54 57.95 47.08 56.25 52.08 63.09 60.0 54.77 45.27 51.81 36.88 60.34 53.62

29.25 23.60 26.05 21.43 33.15 31.81 15.53 14.92 17.70 18.41 25.0 22.32 20.16 19.22 17.13 12.60 18.27 14.62 21.24 14.32

T

Degree of freedom

Significance level

1.976

48.94

0.054*

2.395

50.0

0.020*

2.088

49.92

0.042*

0.286

49.33

0.776

3.553

45.92

0.001*

2.041

43.89

0.047*

0.609

45.42

0.546

0.526

42.62

0.602

3.271

49.79

0.002*

1.314

50.0

0.195

2.297

48.94

0.026*

* A higher score indicates better condition

The results of this study were inconsistent with studies conducted in other countries such as Lundoglu in Turkey with mean overall quality of life score of 65, Tagi in Japan with 61, Vezcoez in Spain with 65, and Fugi Sava in Japan with 68 (20-23). The results of the present study are indicative of lower scores in dimensions of quality of life compared to studies conducted abroad. A reason for this could be adequate dialysis in other countries compared to the dialysis carried out in Iran, and studies conducted show inadequate dialysis (24). Branvald explains that with the development of hemodialysis, thousands of lives of patients with advanced chronic renal failure have been saved, and their mortality rate dramatically reduced. Obviously, by increasing number of dialysis sessions and nutritional improvement, quality of life of these patients will drastically improve (25). In the present study, majority of patients were

dialyzed 12 hours per week, on average, over one or two sessions. While in other countries dialysis time is 20-24 hours per week. The low duration of dialysis in the patients in this study could be the reason for low quality of life of these patients. In this study, the physical functioning dimension had the lowest score, and mental health had the highest mean score, which agrees with Fugi Sava’s study and disagrees with Raymond’s study in Holland (23, 26). The reason for unfavorable physical dimension is related to renal complications. In terms of mental health, it seems cultural and religious attitudes in the society have been involved, and at the time of data collection and interview with patients, despite physical problems, most patients were still thankful of God and stated that they were satisfied with whatsoever He has ordained. Compared to women, in all 8 dimensions, men scored higher; this difference was

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significant in most dimensions, which agrees with some studies (27-28, 16) and disagrees with others (23, 4, and 17). It appears this difference roots in different attitudes of men and women toward life problems. In a study by Taguy, compared to men, women were reported to have more experience of frustration, feelings of fear, and more intense fright (29). The results showed that quality of life decreased with increasing age. Age is an important effective factor in quality of life. With growing older, due to physiological changes of aging, passage of time, and addition of other diseases to the initial disease, quality of life declines especially in the physical functioning dimension. These people may feel inadequate due to separation from their children that may be in transitional stage of life like marrying and making a family, and because of increased dependencies on children due to diseases and subsequent disabilities, and reduced effectiveness, and thus could develop problems in terms of mental component summary, as well. This result is in agreement with results of a study by Taghizadeh, but not with other studies that consider no relationship between age and quality of life (4, 17). Experts believe that marital status is a predicting factor in quality of life. The presence of a supportive spouse is effective in reducing stress, coping with chronic illness, adherence to treatment, and reducing mortality and morbidity. In this study, married patients had better quality of life than the widowed, which concurs with results of study by Vossoghi. This finding disagrees with results of studies by Taghizadeh and by Moorch that confirm insignificant relationship between marital status and quality of life, and also, with Rambode study that found significant

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relationship, and with the study by Taeibi that confirms the same relationship but in the physical functioning dimension only (16, 28, 4, 27). In this study, although mean overall quality of life score in patients with university education was 16 points higher than in illiterate patients, which meant patients with higher education had better quality of life, this difference was nonetheless insignificant. This could be justified by the low number of educated patients. This result was in line with results of study by Taeibi, but not with results of studies that showed significantly higher quality of life with higher education (28, 4, 16-17). People with higher education try to find out about their disease and how they should care for themselves. They are also more capable of being taught and follow instructions of the doctor and treatment team with care. Therefore, they have better quality of life. In terms of spouse’s education, the differences in role limitation dimensions were significant due to physical and mental health problems. This has not been considered in other studies. Spouse’s education is considered a positive point in having a better life, and this leads to a healthier feeling in physical and mental dimensions. No significant difference was found in quality of life between employed and unemployed patients. This finding is in line with results of other studies (27, 1718). Employment status is one of the most important factors in quality of life. The insignificant difference found in this study was probably due to low number of employed patients. There was no significant difference in mean score of quality of life in number of children, which disagreed with findings of Rambode (17). In this study, no significant

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Health-related quality of life in dialysis

relationship was found between duration of treatment with hemodialysis and quality of life, which concurred with results of Rambode study, but not with study by Taghizadeh (4, 17). In terms of economic status, the results showed that people with higher income have better quality of life, but this difference was only significant in physical component summary and dimension of role limitation due to physical health problems, which did not agree with results of other studies (16-18). Mean quality of life in the 8 dimensions and also physical and mental components summary did not show a significant difference in place of residence, insurance status, or number of dialysis per week. Since in this study, conditions of life in urban and rural areas are nearly the same, thus, a significant relationship was not observed. The insignificant relationship between quality of life and insurance status and frequency of dialysis per week could be explained by the limited number of patients without insurance and low number of patients with more than three sessions of dialysis per week. Conclusion

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Based on the findings of this study, it is recommended that facilities be provided for the patients to and from hemodialysis centers. Also, educational programs should be designed to raise their awareness, increase their self-confidence, help them cope with illness, and improve their quality of life, especially for women, and should be so planed and implemented that jobs can be matched with physical conditions, and they can work and earn an income to support themselves and their families. Limitations of this study were its sectional method and relatively low number of subjects. In order to further investigate the effects of diseases on quality of life, longitudinal studies are recommended. Acknowledgements This article is the result of a research project approved by the Jahrom University of Medical Sciences. We extend our sincere appreciation to the Research Deputy of Jahrom University of Medical Sciences and the hemodialysis staff at the Shahid Motahari teaching center in Jahrom, and also all the participating patients that helped us in this study.

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