I have a research plan and 5 references, and you can add one or two references. Academic writing is general. - Management
I want you to write a paper on a topic ( What impact does kidney disease have on the patient, his / her family, and the healthcare providers?) 1500 words.
I have a research plan and 5 references, and you can add one or two references. Academic writing is general.
Attached references and research plan.
I don't need generic medical terms.
One or two references can be added.
Title
What impact does kidney disease have on the patient, his/her family, and the healthcare providers ?
Introduction
· a definition of 'kidney disease' (with a source). What kinds of healthcare providers are involved? Is it only hospitals?
· to explain why this question is important these days.
Thesis statement
We will go through the effect of health care providers and a good family relationship on the psychological state of the kidney patient and coexistence with the disease naturally.
Main Body
1. Paragraph 1 impact does kidney disease have on the patient.
1.1- The psychological impact on the kidney patient.
1.2- Discovering kidney disease and entering the stage of depression.
1.3- The effect of kidney disease on the patient's general life.
1.4- Provide emotional support from the family and health care providers to help the patient accept the disease.
1.5- The positive effect of the psychological on acceptance of dialysis and coexistence with kidney disease.
2. Paragraph 2 impact does kidney disease have on his / her family.
2.1- The psychological impact of a kidney patient on the family.
2.2- The social and financial impact of a kidney patient on the family.
2.3- The positive impact when providing emotional support to the family of a kidney patient.
3. Paragraph 3 impact does kidney disease have on the healthcare providers.
3.1- Provide psychological and emotional support to the patient and his family.
3.2-
3.3-
Conclusion
In kidney disease, a person may develop a state of panic when learning of his injury. The family's intervention and their emotional influence greatly helps in accepting treatment and coping with the disease
Wang and Yang Int J Ment Health Syst (2018) 12:33
https://doi.org/10.1186/s13033-018-0212-4
International Journal of
Mental Health Systems
Does chronic disease influence
susceptibility to the effects of air pollution
on depressive symptoms in China?
Qing Wang1† and Zhiming Yang2*†
Background
The Chinese government encouraged the growth of
industries and urbanization since 1978. However, the
associated rapid economic development has caused
environmental issues, and China is now one of the most
polluted countries in the world [1–3]. For example, the
annual average Total Suspended Particulates (TSP) con-
centration regularly exceeds 400 μg/m
3
in China [4],
which is significantly higher than that in large European
cities (e.g. Oslo, 15 μg/m
3
; Marseille, 18 μg/m
3
) [5] and
World Health Organization (WHO) primary (80 μg/m
3
)
and secondary (60 μg/m
3
) standards [6, 7].
Air pollution is believed to be associated with depres-
sive symptoms [8]. Potential biological mechanisms
*Correspondence: [email protected]
†Qing Wang and Zhiming Yang are Joint first authors
2 Donlinks School of Economics and Management, University of Science
and Technology Beijing, Beijing 100083, China
Full list of author information is available at the end of the article
relating to depressive symptoms include reactivity to
exogenous stressors; alterations of neurohumoral,
immune, and autonomic regulation; dysfunction of
neuro transmitter systems; and oxidative stress [9]. Cell
© The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,
provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license,
and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/
publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
mailto:[email protected]
http://creativecommons.org/licenses/by/4.0/
http://creativecommons.org/publicdomain/zero/1.0/
http://creativecommons.org/publicdomain/zero/1.0/
Wang and Yang Int J Ment Health Syst (2018) 12:33 Page 2 of 12
cultures and experimental animals studies have shown
neuropathological effects from air pollution exposure
[10–12], and previous empirical studies have observed
that air pollution increases the prevalence of depressive
symptoms in Korea, Japan, and the Netherlands [8, 13–
15]. Furthermore, an increasing number of emergency
department visits for depression in Canada and Korea
have been documented [16, 17].
Depression is a serious problem in China [18, 19 ]: in
2013, 36 million years of healthy life were lost to mental
illness in China, and estimates suggest that by 2025, 39.6
million years of healthy life will be lost (10% increase)
[20]. Although little is known about the asso- ciation
between air pollution and depression, several Chinese
studies have found a relationship between expo- sure to air
pollution and happiness [21, 22], depressive symptoms
[23], cognitive functions [24, 25] and hospi- tal admissions
for mental disorders [26], when results were adjusted for
demographics and socioeconomic status. It is considered
that a further decline in air qual- ity could cause an
increased risk to health and an asso- ciated increase in
depressive symptoms. Therefore, this study uses nationally
representative data to estimate the association between air
pollution and depression meas- ured by the Center for
Epidemiologic Studies Depression (CES-D) scale.
Air pollution regulations based on observed health
effects in the general population may be insufficient to
protect exceptionally vulnerable subgroups. Incon-
sistent study results have been found within past study
cohorts. For example, no significant association
between air pollution exposure and depressive symp-
toms was found in a Boston-area study [27], although
other American studies reported that exposure to air
pollution was related to anxiety symptoms [28], which
often have a comorbidity with depression [29]. One
American study found that stroke victims were more
susceptible to the effects of air pollution with respect to
cognitive functions [30]. Thus, it is believed that
chronic disease (e.g. hypertension), which is often
regarded as a marker of inflammation and vascular
dysfunction, may mediate an association between air
pollution and depressive symptoms [31, 32]. Compared
to people in good physical health, the well-known
adverse mental health effects of air pollution may mean
that respondents with chronic disease are likely to
believe that their physical health is being damaged [33–
35]. However, the role of an individual’s physical health
status in the association between air pollution and
depression symptoms has not yet been addressed in
China. Therefore, this study aims to assess which
individuals have a greater vulnerability to the adverse
effects of air pollution [21].
Data and methods
Data
Individual sample data and a group of city-level vari- ables
were obtained to evaluate the relationship between air
pollution, chronic disease, and depressive symptoms.
Individual data were collected from CHARLS 2011 and
2013, which were national representative surveys con-
ducted with middle-aged and elderly Chinese residents
(aged 45 years and above) using face-to-face computer-
assisted personal interviews. The CHARLS question- naire
included the following modules: demographics, family
structure/transfer, health status and functioning,
biomarkers, health care and insurance, work, retirement
and pension, income and consumption, assets (individual
and household), and community-level information. These
surveys were approved by the ethics committee of the
Institutional Review Board of Peking University.
Using multi-stage stratified probability-proportionate-
to-size sampling, the sample in CHARLS represented
approximately 10,000 households in 150 counties/dis-
tricts (a total of 450 villages/resident communities). The
baseline survey was conducted between June 2011 and
March 2012 with a response rate of 80.5% and a total
sample of 17,545 respondents. A total of 15,020 (86%)
respondents participated in the follow-up survey in 2013,
but 2525 (14%) respondents had died or declined partici-
pation in the study. In this study, CHARLS 2011 and 2013
panel data were constructed to estimate the relation- ship
between air pollution and depressive symptoms for
15,020 respondents (15,020 × 2 = 30,040 samples). Of the
respondents, 47% were male with a mean age of 60 years.
Ages and gender distribution were very similar to those
in the 6th national census conducted in 2010 [36].
City-level variables included monthly temperature,
monthly relative humidity, and annual air pollution. Daily
meteorological data from 839 stations in 2011 and 2013
were collected from the China Meteorological Science
Data Sharing Service Network—China Ground Climate
Daily Data. The station-level data were aggregated at a city
level by matching stations to the closest city based on the
exact longitude and latitude of the weather station and the
longitude and latitude of the county centroid. The average
monthly temperature and relative humidity of CHARLS
125 sample cities were then calculated from daily data.
Based on survey city and month, the results from 15,020
respondents in the two CHARLS waves were combined
with the meteorological data from 125 cities.
The annual sulfur dioxide (SO2) and TSP emissions from
273 cities in 2011 and 2013 were obtained from the 2012
and 2014 China City Statistical Yearbook. Based on survey
year and city, 12,046 respondents of the 15,020
respondents in the two CHARLS waves were matched to
the air pollution data from 101 cities. After excluding 412
Wang and Yang Int J Ment Health Syst (2018) 12:33 Page 3 of 12
respondents that provided missing values from 12,046
respondents, 11,634 respondents were included, and the
final sample size was 23,268 (11,634 × 2) samples from
101 cities. Figure 1 presents a flow chart of the study
process.
Variables
Depressive symptoms
A modified seven-item version of the CES-D scale was
constructed to measure depressive symptoms [37].
Respondents reported the frequency of experiencing the
following seven depressive symptoms during the past
week: (1) “was bothered by things,” (2) “had trouble keep-
ing mind on what was doing,” (3) “felt depressed,” (4) “felt
everything he/she did was an effort,” (5) “felt fearful,” (6)
“sleep was restless,” and (7) “felt lonely.” Each answer was
encoded from 1 to 4: 1 = rarely or none, 2 = some or a lit-
tle, 3 = occasionally or a moderate amount, and 4 = most
or all of the time, with total scores ranging from 7 to
28. A summed score of the seven items was calculated,
with lower scores indicating fewer depressive symptoms.
This shortened seven-item CES-D scale is a widely used
indicator for depressive symptoms [38, 39]. Its validity,
reliability, and cultural equivalence have been proven in
China [40]. In our data set, CES-D was also demon- strated
to have high internal consistency (Cronbach’s
alpha = 0.82) and to construct validity (Kaiser–Meyer–
Olkin = 0.87) according to the standards of Meulen et al.
[41], Kara [42], and Aly [43], which suggest that if the
Cronbach’s alpha and Kaiser–Meyer–Olkin test value
exceeds the recommended level of 0.70 then data is con-
sidered to be highly reliable [41–43].
Air pollution
Following previous studies, SO2 and TSP emission inten-
sity, SO2 and TSP emissions per capita, and SO2 and TSP
emissions per unit area were calculated to measure air pol-
lution [44–47]. Pollution intensity refers to the indicator of
pollution emissions per industrial gross domestic product
(GDP) (industrial economic output). Log transformation of
air pollution data was applied to minimize skewness [45].
Chronic disease
A categorical variable for a doctor to use in diagnosing
chronic disease was created based on the question, “Have
you ever been diagnosed with hypertension, dyslipidemia,
diabetes or high blood sugar, cardiovascular disease (heart
attack, coronary heart disease, angina, congestive heart
failure, stroke or other heart problems), cancer or malignant
tumor, liver disease, chronic lung disease, kid- ney disease,
stomach or other digestive disease, arthritis or rheumatism
and asthma by a doctor?” The variable equaled 1 or 0 for
respective replied of “yes” or “no”.
Estimation Strategy
Descriptive analysis was first conducted to describe sam-
ple characteristics of the total sample and for chronic dis-
ease status. Frequencies with percentages were presented
for categorical variables (gender, marital status, educa-
tion, employment status, insurance status) and means
with standard deviations for continuous variables (CES-
D, air pollution indicators, climate indices, income, and
age). P-values were calculated using the Chi square test
for categorical variables, and one-way Analysis of Vari-
ance (ANOVA) for continuous variables between groups
(with or without chronic disease).
A random effects model was then applied to link air pol-
lution intensity with depressive symptoms. Omitted varia-
ble bias was controlled using the random effects model. The
individual random effects model is presented as follows,
Depressiveijt = a0 + Airjta1 + Xijta2 + ui + vt + eijt ,
(1)
where a0, a1, a2 are the parameters to be estimated; ui and vt
are the individual effects and year fixed effects, respec-
tively; eijt is the idiosyncratic error term; and Depres- siveijt
is the depressive symptoms of person i in city j in year t;
Airjt is a variable indicating the log of air pollution
intensity, Xijt represents an individual’s demographic,
socioeconomic status, health behavior, and city-level cli-
mate variables in the living area. To be more specific, the
demographic variables included whether male or female,
marital status [reference group: married with spouse
present (common-law marriage was considered mar- ried)],
and age; socioeconomic status was measured by
Wang and Yang Int J Ment Health Syst (2018) 12:33 Page 4 of 12
ijt
ijt
ijt
ijt
ijt
ijt
household income per capita, education level, employ-
ment status, insurance status, and rural/urban residence;
educational attainment was defined at four levels (infor-
mal education, informal education but can read and
write, primary school, and junior high school and above),
and a categorical variable for educational attainment
with four values was constructed, with informal educa-
The total CES-D scale used to evaluate depressive
symptoms of middle-aged and elderly individuals ranged
between 7 and 28, which represents a limited dependent
variable. Therefore, least square regression was directly
applied to render inconsistent estimates [50, 51]. The Tobit
model was used for robust analysis in this respect, and
marginal effects were reported,
tion serving as the reference group; household income
was divided by the number of household members and
household income per capita was subsequently ranked
and divided into five pentiles, with the lowest group
Depressive
∗
= c0 + Airjtc1 + Chronicijtc2 + Airjt
× Chronicijtc3 + Xijtc4 + ui + vt + eijt ,
(3)
serving as a reference; employment status was catego-
rized into three groups: unemployed (including retired),
Depressiveijt = 7 if Depressive
∗ ≤ 7, (4)
self-employed, and wage earner; for health insurance
coverage, respondents were recoded into a dummy vari-
able with three values [the urban employee-based basic
Depressiveijt = Depressive
∗
if 7 < Depressive
∗
< 28,
(5)
medical insurance scheme (UEBMI), the rural new coop-
erative medical scheme (NCMS), and the urban resident-
Depressiveijt = 28 if Depressive
∗ ≥ 28, (6)
based basic medical insurance scheme (URBMI)], with where c0, c1, c2, c3, c4 are the parameters to be estimated;
uninsured respondents as the reference group; current Depressive∗ is a latent variable and Depressiveijt is its
smoker and drinker were included as indicators of the
respondents’ current health behaviors; and city-level
average monthly temperature, relative humidity, and city
dummy variables were also controlled.
The interaction between chronic disease and air pollu-
tion intensity was then controlled in multivariate regres-
sion to establish whether chronic disease influences an
individual’s susceptibility to depressive symptoms with
respect to air pollution,
Depressiveijt = b0 + Airjtb1 + Chronicijtb2 + Airjt
× Chronicijtb3 + Xijtb4 + ui + vt + eijt ,
(2)
where b0, b1, b2, b3, b4 are the parameters to be esti-
mated; Chronicijt is a dummy variable indicating whether
a respondent has a chronic disease; and Airjt× Chronicijt
is the interaction between chronic disease and air pol-
lution intensity after decentralization. Decentralization
of air pollution indicators was calculated by subtracting
the mean of city-level air pollution intensity from air pol-
lution intensity in each city and then dividing it by the
standard deviation of city-level air pollution intensity
using the center-command in Stata 14 [48].
Analyses were then stratified according to chronic
disease characteristics. Depressive symptoms may also
affect an individual’s physical health status and lead to
endogenous issues [49]. Stratification was conducted to
eliminate any possible endogenous issues by excluding
respondents with chronic diseases (hypertension, dys-
lipidemia, diabetes or high blood sugar, cardiovascular
diseases, arthritis and asthma) because such diseases may
stem from depressive symptoms. Under these conditions
no other possible methods were available for now.
Wang and Yang Int J Ment Health Syst (2018) 12:33 Page 5 of 12
observable variable. A robust standard error was
derived using bootstrapping methods and conducting
500 boot- strap replications.
In addition, by using the Tobit model with stratified
samples, the effects of SO2 and TSP emission per capita/
per unit area on depression were regressed (and are pre-
sented in Appendix: Table 4). The results were
consistent with those using air pollution emission
intensity. Stata version 14 was used for all analyses [48].
Results
Participant characteristics and average air pollutant
intensity across chronic disease are shown in Table 1.
On average, SO2 and TSP emissions accounted for
82.950 (SD = 78.355) and 45.571 (SD = 49.025) tons per
100 million Chinese yuan of industrial GDP, respec-
tively. SO2 emissions per unit area and per capita were
6.812 (SD = 8.307) tons/km2 and 135.137 (SD = 120.211)
tons/10,000 people; and TSP emissions per unit area and
per capita were 3.079 (SD = 3.495) tons/km2 and 70.938
(SD = 81.064) tons/10,000 people; and average tem-
perature and humidity were 26.599 °C (SD = 3.935) and
73.253% (SD = 7.603), respectively.
The mean age of respondents was 60 (SD = 9.989)
years; 48% of respondents (11,108/23,268) were male;
88% (20,414/23,268) were married or cohabit- ing; 39%
(9016/23,268) lived in an urban area; 44%
(10,191/23,268) of respondents had no formal edu-
cation; 33% (7734/23,268) were unemployed; 44%
(10,162/23,268) were self-employed; and the major-
ity had health insurance [94% (21,813/23,268)]. A total
of 33% (7713/23,268) reported smoking and 33%
(7756/23,268) reported drinking alcohol. The
Wang and Yang Int J Ment Health Syst (2018) 12:33 Page 6 of 12
a Frequencies with percentages were presented for categorical variables. P-values were calculated by Chi square test between groups having chronic disease or not
b Means with standard deviations were presented for continuous variables, and P-values were calculated one-way ANOVA between groups having chronic disease or
not
respondents earned an average of 8175 (SD = 14,912)
Chinese yuan per year per capita. The average depres-
sive symptoms score was 11.623 (SD = 4.664). Com-
pared to participants with chronic disease, those without
chronic disease were more likely to report lower
depressive symptoms [12.176 (SD = 4.858) versus
10.538 (SD = 4.043)] but not more likely to be exposed
to air pollution.
Models 1 and 3 from Table 2 show the correlation
between air pollution and depressive symptoms in China
after adjusting for multiple covariates. Increasing lev- els
of air pollution were found to be significantly asso- ciated
with higher depressive symptoms: an increase in SO2 and
TSP emission intensities of 1% was associated with
increasing depressive symptoms scores by 1.266
(SE = 0.107, P < 0.001, 95% CI 1.057–1.475) and 1.318
Table 1 Statistical description
Variable All sample
(N = 23,268)
Group with chronic
disease (N = 15,412)
Group
without chronic
disease (N = 7856)
Group with chronic
disease VS Group
without chronic disease
Mean Std. Dev. Mean Std. Dev. Mean Std. Dev. P-valuea
Air pollution emission intensity (tons per 100 million Chinese yuan)
SO2 82.950 78.355 82.602 74.980 83.632 84.587 < 0.001
TSP 45.571 49.025 46.510 50.816 43.729 45.253 < 0.001
Air pollution emission per unit area (tons/km2)
SO2 6.812 8.307 6.667 8.728 7.097 7.403 < 0.001
TSP 3.079 3.495 2.998 3.576 3.236 3.326 < 0.001
Air pollution emission per capita (tons/10,000 people)
SO2 135.137 120.211 132.127 118.256 141.042 123.753 < 0.001
TSP 70.938 81.064 70.173 80.964 72.440 81.243 < 0.001
Climatic indexes
Average monthly temperature (0.1 °C) 265.990 39.353 266.038 39.678 265.894 38.710 < 0.001
Average monthly relative humidity (%) 73.253 7.603 73.077 7.634 73.599 7.529 < 0.001
Depressive symptoms 11.623 4.664 12.176 4.858 10.538 4.043 < 0.001
Age 60.101 9.989 61.101 9.834 58.139 10.000 < 0.001
Income (Chinese yuan/year) 8175 14,912 7970 13,343 8576 17,583 0.011
n % n % n % P-valueb
Male 11,108 47.739 7165 46.490 3943 50.191 0.010
Unmarried 2854 12.266 1991 12.919 863 10.985 0.022
Living in urban area 9016 38.748 5947 38.587 3069 39.066 0.730
Education < 0.001
No education 5973 25.670 4145 26.895 1828 23.269
No education but can read/write 4218 18.128 2946 19.115 1272 16.191
Primary school 5181 22.267 3498 22.696 1683 21.423
Junior high school and above 7896 33.935 4823 31.294 3073 39.117
Employment status < 0.001
Unemployed 7734 33.239 5623 36.485 2111 26.871
Self-employed 10,162 43.674 6710 43.537 3452 43.941
Wage earner 5372 23.087 3079 19.978 2293 29.188
Insurance 0.037
Uninsured 1455 6.253 854 5.541 601 7.650
NCMS and URBMI 18,635 80.089 12,389 80.385 6246 79.506
UEBMI 3178 13.658 2169 14.074 1009 12.844
Health behavior
Current Smoker 7713 33.149 4757 30.866 2956 37.627 < 0.001
Current Drinker 7756 33.333 4932 32.001 2824 35.947 0.005
Wang and Yang Int J Ment Health Syst (2018) 12:33 Page 7 of 12
Table 2 Association of air pollution intensity and depressive symptoms and the role of chronic disease (N = 23,268)
Variables Influence of SO2 emission intensity on depressive
symptoms
Influence of TSP emission intensity
on depressive symptoms
Model 1 Model 2 Model 3 Model 4
Coef. Std. Err. Coef. Std. Err. Coef. Std. Err. Coef. Std. Err.
Log of SO2 intensity 1.266*** 0.107 1.093*** 0.116 – – – –
Log of TSP intensity – – – – 1.318*** 0.082 1.115*** 0.092
Chronic disease – – 1.384*** 0.068 – – 1.388*** 0.068
Log of SO2 intensity × Chronic disease – – 0.217*** 0.084 – – – –
Log of TSP intensity × Chronic disease – – – – – – 0.281*** 0.071
Log of average monthly temperature 0.189** 0.085 0.176** 0.085 0.201** 0.087 0.191** 0.087
Log of average monthly relative humidity − 0.690** 0.333 − 0.693** 0.332 − 0.445 0.335 − 0.451 0.333
Age group
50–59 0.248*** 0.090 0.134 0.089 0.263*** 0.090 0.148* 0.089
60–69 0.148 0.105 − 0.057 0.104 0.174* 0.104 − 0.031 0.103
More than 70
Male
− 0.396***
1.270***
0.131
0.091
− 0.606***
1.269***
0.130
0.090
− 0.368***
1.282***
0.131
0.091
− 0.578***
1.283***
0.130
0.090
Unmarried 0.680*** 0.121 0.701*** 0.119 0.682*** 0.121 0.701*** 0.119
Living in urban area
Education
− 0.400*** 0.104 − 0.398*** 0.103 − 0.395*** 0.104 − 0.387*** 0.103
No education but can read/write 0.414*** 0.118 0.373*** 0.116 0.416*** 0.118 0.376*** 0.116
Primary school − 0.043 0.112 − 0.081 0.110 − 0.039 0.112 − 0.077 0.110
Junior high school and above − 0.470*** 0.114 − 0.454*** 0.112 − 0.461*** 0.114 − 0.448*** 0.112
Employment status
Self− employed − 0.165* 0.089 − 0.109 0.088 − 0.152* 0.088 − 0.096 0.088
Wage earner − 0.351*** 0.090 − 0.262*** 0.089 − 0.354*** 0.090 − 0.265*** 0.089
Insurance
NCMS and URBMI − 0.061 0.130 − 0.123 0.129 − 0.052 0.129 − 0.113 0.128
UEMBI − 0.432*** 0.152 − 0.520*** 0.151 − 0.418*** 0.151 − 0.503*** 0.150
Income group
21–40th percentile 0.328*** 0.100 0.335*** 0.099 0.340*** 0.100 0.349*** 0.099
41–60th percentile 0.078 0.096 0.068 0.095 0.091 0.096 0.082 0.095
61–80th percentile − 0.073 0.096 − 0.068 0.095 − 0.063 0.096 − 0.056 0.095
81–100th percentile − 0.289*** 0.101 − 0.296*** 0.100 − 0.288*** 0.101 − 0.295*** 0.100
Health behavior
Current drinker 0.040 0.072 0.108 0.072 0.0459 0.072 0.114 0.072
Current smoker
Constant
− 0.196**
7.165***
0.081
1.548
− 0.156*
7.025***
0.080
1.562
− 0.186**
7.219***
0.081
1.538
− 0.144*
7.079***
0.080
1.544
City dummy variables YES YES YES YES
Adjusted R2 0.139 0.165 0.139 0.165
Wald Chi square 2126*** 2596*** 2228*** 2707***
Models 1–4 are estimated using the xi:xtreg-command in Stata 14. Decentralization was calculated using the center-command
* P < 0.10; ** P < 0.05; *** P < 0.01
(SE = 0.082, P < 0.001, 95% CI 1.157–1.480), respec-
tively. Models 2 and 4 from Table 2 present the interac-
tion between air pollution and chronic disease and their
effect on depressive symptoms. After controlling for the
interaction of air pollution and chronic disease, a posi-
tive correlation between air pollution and depressive
symptoms was observed, as expected. An 1% increase
in the intensities of SO2 and TSP emissions was associ-
ated with 1.237 (1.093 (SE = 0.116, P < 0.001, 95% CI
0.866–1.320) + 0.217 (SE = 0.084, P = 0.009, 95% CI
0.053–0.380) × 15,412/23,268 = 1.093 + 0.217 × 66%)
and 1.301 (1.115 (SE = 0.092, P < 0.001, 95% CI 0.934–
1.296) + 0.281 (SE = 0.071, P < 0.001, 95% CI 0.143–
0.420) × 66%) higher depressive symptoms scores,
Wang and Yang Int J Ment Health Syst (2018) 12:33 Page 8 of 12
respectively. In addition, due to an 1% increase in the
intensities of SO2 and TSP emissions, the depressive
symptoms scores for respondents with chronic disease
increased by 1.903 (1.384 (SE = 0.068, P < 0.001, 95%
CI 1.250–1.518) + 0.217 (SE = 0.084, P = 0.009, 95% CI
0.053–0.380) × log(82.950)) and 1.854 (1.388 (SE = 0.068,
P < 0.001, 95% CI 1.254–1.522) + 0.281 (SE = 0.071,
P < 0.001, 95% CI 0.143–0.420) × log(45.571)), respec-
tively. Given the same intensities of SO2 and TSP emis-
sions, respondents with chronic disease had higher scores
for depressive symptoms by 0.217 (SE = 0.084, P = 0.009,
95% CI 0.053–0.380) and 0.281 (SE = 0.071, P < 0.001,
95% CI 0.143–0.420) than those without chronic disease.
Models 1–4 from Table 3 show the results strati- fied
using chronic disease characteristics; models 5–8 show
results using the Tobit model; models 9–12 show the
results stratified using chronic disease character- istics
and the Tobit model. Robust analysis shows that the
results obtained were consistent with those using the
random effects model. According to models 10 and 12
from Table 3, for individuals with cancer or malig- nant
tumor, chronic lung diseases, liver diseases, kid- ney
disease, and stomach diseases, when the SO2 and TSP
emission intensities increased by 1% individu-
als showed an increase in depressive symptom scores
of 0.844 (0.788 (SE = 0.128, P < 0.001, 95% CI 0.537–
1.039) + 0.221 (SE = 0.091, P = 0.015, 95% CI 0.044–
0.399) × 2669/10,508 = (0.788 + 0.221 × 25%) and 0.818
(0.765 (SE = 0.118, P < 0.001, 95% CI 0.534–0.997) + 0.208
(SE = 0.107, P = 0.051, 95% CI 0–0.417) × 25%), respec-
tively. In addition, due to an 1% increase in the intensi- ties
of SO2 and TSP emissions, respondents with these chronic
diseases scored higher for depressive symp- toms by
1.292 (0.869 (SE = 0.102, P < 0.001, 95% CI
0.668–1.069) + 0.221 (SE = 0.091, P = 0.015, 95% CI
0.044–0.399) × log (82.000)) and 1.208 (0.866 (SE = 0.114,
P < 0.001, 95% CI 0.643–1.090) + 0.208 (SE = 0.107,
P = 0.051, 95% CI 0–0.417) × log(43.885)), respectively.
Given the same intensities of SO2 and TSP emissions,
individuals with chronic disease had higher scores for
depressive symptoms by 0.221 (SE = 0.091, P = 0.015, 95%
CI 0.044–0.399) and 0.208 (SE = 0.107, P = 0.051, 95% CI
0–0.417) than those without chronic disease. However,
the impacts of air pollution were reduced after eliminat-
ing the endogenous variable, which supports the hypoth-
esis that depressive symptoms influence physical health.
Discussion
To the best of the authors’ knowledge, this is the first
published article to elucidate the role of chronic disease
in an association between air pollution and depressive
symptoms within the Chinese population, who prefer
to acknowledge poor mental conditions …
Offer, Daniel, et al. Dialysis Without Fear : A Guide to Living Well on Dialysis for Patients and Their
Families, Oxford University Press, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/leicester/
Created from leicester on 2020-11-08 23:22:36.
T
Six
Dealing with Emotions
The Psychological Impact of
Dialysis
rue or false: people who are on dialysis are unhappier than
people who are not on dialysis? If you answered true you’ll
probably be surprised to hear that a carefully designed research study
has proven otherwise. The study, led by a psychologist, Jason Riis,
while he was completing graduate work at the University of Michi-
gan, compared forty-nine individuals on hemodialysis, three times
weekly, with forty-nine healthy individuals of the same age, race, ed-
ucation, and sex.1 All of the subjects were given electronic devices
that prompted them to record their moods throughout the day.
Moods were rated on a 5-point scale from “very pleasant” to “very
unpleasant” and subjects were given the opportunity to answer these
questions privately and repeatedly over time.
When the results of the two groups were compared, the re-
searchers found that the levels of happiness were about the same for
the two groups. The study also found that the dialysis patients over-
estimated how happy the healthy people would be and the healthy
people underestimated how happy the dialysis patients would be.
Why is it that we are so quick to assume that dialysis leads to unhap-
piness? On the contrary, we the authors have come to believe that if
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Offer, Daniel, et al. Dialysis Without Fear : A Guide to Living Well on Dialysis for Patients and Their
Families, Oxford University Press, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/leicester/
Created from leicester on 2020-11-08 23:22:36.
Dealing with Emotions 115
you were relatively happy before dialysis, in time, you will be happy
after. Alternatively, if you were relatively unhappy before dialysis, you
will still be unhappy after. How a person copes with dialysis and the
attitude he or she adopts toward it is often reflective of how someone
has managed to cope and the attitudes he or she has learned to adopt
throughout life.
Of course, dialysis is initially shocking for everyone. This initial
shock can cause a serious crisis for many individuals. Going on dialy-
sis can result in depression, anger, anxiety, and even occasionally an
emotional breakdown. It can also result in severe crisis in family rela-
tionships, which occasionally can result in separation and divorce.
However, in these cases the marriage was suffering to begin with.
Dialysis is simply the straw that breaks the camel’s back. There is no
question that individuals who have no other physical illnesses (such
as diabetes, strokes, heart disease) often do better emotionally than
individuals who have other major physical illnesses for the simple fact
that their burden is lighter. But after the initial shock has passed and
a person has become used to the new routines of the dialysis, he or
she settles down to live life within the constraints of the treatment.
During this initial period of shock, what are the tools that a per-
son can use to help ease this emotional distress? In this chapter we
will identify and discuss some of the most common emotional re-
sponses to dialysis. In addition, we will recommend ways to help you
deal with this emotional turbulence. The good news is that like most
kinds of turbulence, eventually this too subsides. By addressing and
tending to these emotional bumps, you may eventually, as the afore-
mentioned study shows, find yourself just as happy as the next guy.
Throughout the years that Daniel has been visiting dialysis clinics
we’ve met many rather well-adjusted, seemingly happy individuals,
but most of these acquaintances rarely opened up to us about their
trials and tribulations when first starting dialysis. Nor did they tell us
much about the sources of strength they used to help them survive
the tough times. But in the course of researching this book, Susan
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Offer, Daniel, et al. Dialysis Without Fear : A Guide to Living Well on Dialysis for Patients and Their
Families, Oxford University Press, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/leicester/
Created from leicester on 2020-11-08 23:22:36.
116 D i a l y s i s w i t h o u t F e a r
met Jeffrey, a pastor for a medium-sized interdenominational church
who spoke candidly about the physical and emotional trauma of first
starting dialysis and the important role that his faith played in help-
ing him to cope.
Jeffrey’s Story, a Hemodialysis
Patient’s Perspective
When Susan meets with Jeffrey, a middle-aged African American
gentleman, he strikes her as just that—a gentle man. Jeffrey has been
on dialysis for only sixteen months and he explains that he is still
adapting to the transition. Like his father before him, Jeffrey suffers
from diabetes that eventually led to his renal failure. His father, one
of twelve children, had begun dialysis many years before. Jeffrey in-
forms Susan that he also has six uncles who have gone on dialysis,
and he says that he can identify at least four generations of diabetics
in his family. Because of this genetic disposition Jeffrey surmises that
he is the first, but likely not the last, of the second generation of fam-
ily members to undergo dialysis.
Just four years earlier Jeffrey had been diagnosed with diabetes.
And one year after that, he was referred to a nephrologist who told
Jeffrey that his kidneys were operating at 40%. Jeffrey attempted to
watch his sugar levels, but he didn’t think he was headed toward re-
nal failure or dialysis. Then two years later he noticed swelling in his
legs and ankles. Every evening he would elevate his legs and every
morning the swelling would be gone. What Jeffrey, who admits he
was in denial, didn’t realize was that the fluid was simply moving
around from one place to another. This routine continued until one
morning, as he was walking into the building where he worked, Jef-
frey collapsed. Paramedics rushed him to the hospital and the next
thing he knew he was being dialyzed.
At first, Jeffrey says he really didn’t think about what it meant to
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http://ebookcentral.proquest.com/lib/leicester/
Offer, Daniel, et al. Dialysis Without Fear : A Guide to Living Well on Dialysis for Patients and Their
Families, Oxford University Press, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/leicester/
Created from leicester on 2020-11-08 23:22:36.
Dealing with Emotions 117
be on dialysis. He just wanted the doctors and nurses to do whatever
it took to make him feel better. But he soon realized, he did not like
the catheter or the cramps he suffered as fluid was removed from his
lungs and body. All told, during his week-long hospital stay the
medical professionals removed forty-five pounds of liquid. After that
week, Jeffrey says he was a different person physically. It wasn’t until
he went to his local dialysis clinic for the first time after leaving the
hospital that dialysis began to impact him emotionally.
How were you affected emotionally?
“Well, my father has been on dialysis for about eight years, so I
had been around it. I had helped him deal with his emotional roller-
coaster, but now I had to face dialysis myself. I think what bothered
me the most was watching my family deal with my illness. My kids
told me that I’d always been the strong one. I’d never been sick. I’d
always visited other people in the hospital and comforted them. So
for my children to see me flat on my back made them feel very help-
less. Having them see me this way was difficult for me. When I was
in the hospital, my daughter didn’t even want to come to see me. She
didn’t want to deal with it. Just now she has started to write some po-
etry about her experience when I went on dialysis. Finally, she is
learning to express herself more.
“I think dialysis was also traumatizing for my wife. We were get-
ting ready to travel, to buy a new home and do a lot of things we’d
dreamed of when the children were grown. I think she just had never
imagined herself in that predicament in her life.”
What was dialysis like for you when you first began?
“When I first started I had a lot of problems with my graft. Not
just anybody could stick me, and that was upsetting too. I have a high
pain tolerance, but it was frustrating when I would get a less ex-
perienced technician. Also the trial and error of trying to find my dry
weight was the most difficult part. I didn’t really know how much
fluid I could have in between sessions, how much would neg- atively
impact me during and after my sessions. When I first began,
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http://ebookcentral.proquest.com/lib/leicester/
Offer, Daniel, et al. Dialysis Without Fear : A Guide to Living Well on Dialysis for Patients and Their
Families, Oxford University Press, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/leicester/
Created from leicester on 2020-11-08 23:22:36.
118 D i a l y s i s w i t h o u t F e a r
I was arriving ten to twelve pounds over my dry weight. That wasn’t
good. I would cramp during and after the session. Now when I come
in, they take off two or three pounds. Unfortunately, I had to learn
how to control my liquids the hard way. Until you start learning what
fluid does to you and what certain foods do to you, you can feel
pretty bad. Adjusting to a new diet was a whole other can of worms
that I had to deal with. Over time I learned about my potas- sium,
phosphorus, and calcium.”
What advice would you give to someone who is new to dialysis?
“Really spend a lot of time talking. Talk about how you feel phys-
ically and emotionally. When I first went on dialysis I read some
pamphlets, but honestly it was as if they were written in Chinese.
They were filled with information. I think it would have been help-
ful for me to read more about the psychological aspects of what a
person goes through in the beginning. I think visiting with a support
group or seeing a counselor might have also been beneficial. I didn’t
do either of these things, although I did regularly read a newsletter
that included personal testimonials. I found reading about other
people’s stories and what they went through to be extremely helpful.
I also had my wife read the testimonials too. They were helpful for
both of us.
“I would also recommend that new patients speak with the veter-
ans in the clinic. Some of the folks here, the older folks (I’m the new
kid on the block), they really helped me through a lot. They would
ask me ‘How are you feeling? What are you going through?’ And they
would tell me what questions I should be asking the medical staff.
Having that kind of support and friendship was really very
advantageous.”
What advice would you give to a family member of someone new to
dialysis?
“Talk to somebody about what you are going through emotion-
ally. At first there are a lot of emotions that the family and especially
the spouse are going through. But they don’t want to share these
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Offer, Daniel, et al. Dialysis Without Fear : A Guide to Living Well on Dialysis for Patients and Their
Families, Oxford University Press, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/leicester/
Created from leicester on 2020-11-08 23:22:36.
Dealing with Emotions 119
emotions with you because they feel that you have enough to worry
about. Despite this, family members also need an outlet or someone
to talk to. I wish initially my wife had done that more. She held a lot
of her emotions in for a long time. I think possibly talking to my fa-
ther and mother, or somebody who had gone through the same
thing, would have helped her a great deal.”
Jeffrey says that when he first began dialysis his wife took time off
from work to drive him dialysis. Because he didn’t want her to feel
like she had to spend so much time caring for him, he tried to get
back on his feet as quickly as possible. Jeffrey tells Susan, “I think
getting back to a relative state of normal where I could drive myself
has helped a lot. I also think it helped that I opened up and said to
her, ‘Tell me how you feel.’ I think she wanted to know what I was
going through emotionally as well. This was important for her. It was
difficult for me, at first, to share my feelings with her. In the be-
ginning I didn’t really like to talk about it. I would just say ‘I’m feel-
ing pretty good!’ ”
Interestingly enough, both Jeffrey and his wife were trying to pro-
tect one another from the distress that they individually were en-
countering. Jeffrey didn’t want to burden his wife with having to take
care of him. He didn’t want to tell her truthfully how he was do- ing
and felt that he had to rebound and adjust just as quickly as pos- sible.
Likewise, his wife felt angry and sad that their life was no longer what
she had envisioned, but since she was the healthy one, she felt she
couldn’t share these emotions with her husband. During a stressful
time the two tended to keep their feelings to themselves. Eventually
when they began communicating more openly and hon- estly with
each other they began to cope better emotionally.
In addition to addressing your emotions, what are some additional
key success factors to living well on dialysis?
“Really, every individual is different. I think if it wasn’t for my
faith, perhaps I would have a very different outlook on dialysis and
on life. Most of my life I’ve tried to encourage people to live well
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Offer, Daniel, et al. Dialysis Without Fear : A Guide to Living Well on Dialysis for Patients and Their
Families, Oxford University Press, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/leicester/
Created from leicester on 2020-11-08 23:22:36.
120 D i a l y s i s w i t h o u t F e a r
despite adversity. Suddenly I had to live as I’ve always preached.
Along with my faith, I also have a strong support system in both my
family and my community, which has helped me to stay positive and
optimistic.”
Are there any benefits to being on dialysis?
“Sure—I’m glad we have it! Dialysis is doing what my kidneys can’t
do. I also think it has made me a better pastor. I’m more pas- sionate
about habits that affect our lives in a negative way. I’ve only missed
one Sunday at church since I’ve been on dialysis. The week I left the
hospital I missed preaching, but the following week I was there. That
first Sunday after I began dialysis I looked out at the con- gregation. I
really looked at the people who had been sick. Many of the
congregants had been ill for years. And I realized that our health
issues are a collective problem. We live in a society that promotes
unhealthy lifestyle habits. Now I’m much more conscious about
healthy living and am an advocate of better health. I’ve even started
a wellness program at the church for people to get their blood sugar
checked regularly.”
Jeffrey tells Susan he credits his faith, his motivation to help oth-
ers, and the support of those around him as giving him the strength
to cope, but he acknowledges that going on dialysis was tough. Phys-
ically it has been hard on him. Emotionally he has grappled with a
sense of failure and weakness, fearful that he has let his family down.
But fortunately Jeffrey’s sense of accountability to his congregants
whom he has preached to for so long has been his saving grace. As he
tells Susan, “For many years I had talked the talk. Now I had to walk
the walk.”
Like the veterans he speaks of, Jeffrey strikes Susan as a man who
has gone to battle with his physical and emotional demons and who
has now crossed over to a safer place. In order to be a role model, Jef-
frey was forced to find a way to cope. He admits his new schedule
and lifestyle still require adjustments, but he also tells Susan he hopes
to start traveling with his wife more, he is working full time,
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Offer, Daniel, et al. Dialysis Without Fear : A Guide to Living Well on Dialysis for Patients and Their
Families, Oxford University Press, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/leicester/
Created from leicester on 2020-11-08 23:22:36.
Dealing with Emotions 121
and he’s looking forward to seeing his daughter graduate from high
school soon. Susan can’t help noticing that he is living well and en-
joying life despite dialysis. Before they part ways, Susan finds herself
contemplating what sources of strength or coping mechanisms she
would draw upon if she were ever to walk in Jeffrey’s shoes.
Once the Shock Subsides: Coping with
Psychological Aftershocks
Like Jeffrey, most patients whom we met told us that it took some
time for their physical health to improve significantly before they
could begin to feel, much less deal, with the substantial emotions as-
sociated with this enormous life change. When they begin to feel bet-
ter physically is when many patients start to feel anxious, depressed,
or angry. Family members are also highly susceptible to these emo-
tions. It is normal and understandable to experience them. But the
people who do not do well on dialysis are the ones who cannot, over
a normal course of time, address and move past these emotional
states. Some individuals never cope well with dialysis. They think
their life has been forever limited and they absolutely hate the thought
of having to go to dialysis three times each week as long as they
live—or until they receive a transplant. Emotionally, these are the
people who do not do well. Now let’s look at some of the most com-
mon emotions that can negatively impact dialysis patients and their
families, what happens to those who do not cope well, and what cop-
ing mechanisms a person can rely on when working through these
emotions.
Denial
Denial is often the very first reaction of many dialysis patients. De-
nial is a state of nonacceptance. When in denial, a person refuses to
accept the fact that he or she is on dialysis. Obviously the person can
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http://ebookcentral.proquest.com/lib/leicester/
Offer, Daniel, et al. Dialysis Without Fear : A Guide to Living Well on Dialysis for Patients and Their
Families, Oxford University Press, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/leicester/
Created from leicester on 2020-11-08 23:22:36.
122 D i a l y s i s w i t h o u t F e a r
see himself or herself receiving the treatment but chooses to believe
that it is temporary and that all will return to normal in a few weeks
or months. In this state a patient typically refuses to follow the diet
or acknowledge the liquid restrictions. He or she continues to act
and behave as before starting dialysis. The patient is neither angry
nor depressed; he or she simply refuses to believe that life on dialysis
is now a reality. As we all know, innocence can be bliss, but dialysis
patients cannot stay in this state forever. It is only a matter of time
before their denial causes their health to decline precipitously.
Sadly, many of the individuals whom we interviewed claimed not
to have believed what the doctors told them regarding their diet and
liquid restrictions. Too many said they had to learn to take care of
themselves and heed their doctor’s advice the hard way. This was un-
fortunate, because this learning path usually meant jeopardizing their
lives. Denial, while common, is not a particularly helpful re- sponse
to the newness of dialysis. As one physician we interviewed said,
“Like so many things in life, dialysis is a head game. Most pa- tients
won’t do well if they struggle and fight against dialysis rather than
work with it. Denial or the inability to come to terms with dial- ysis
prevents some people from doing as well as they might. Can you get
by when you are messy and inattentive and don’t comply with in-
structions? Yes you can, but if you want to do better you need to
have your thoughts together and understand what is being asked of
you. And by understand I generally mean you have to do what you
are told.” Patients are much better served the sooner they can accept
their reality and work within the guidelines that are set forth by their
medical team. One way or another, reality will eventually sink in and
when it does patients are then most often confronted with feelings of
anxiety, depression, or anger.
Anxiety
Anxiety makes one feel uneasy, fearful, nervous, and worried. Physi-
cally one can experience a quickened pulse, lethargy, irritability, and
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Offer, Daniel, et al. Dialysis Without Fear : A Guide to Living Well on Dialysis for Patients and Their
Families, Oxford University Press, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/leicester/
Created from leicester on 2020-11-08 23:22:36.
Dealing with Emotions 123
increased sweating. There are numerous sources of anxiety that pa-
tients associate with dialysis. Let’s start with the whopper, the big
kahuna of them all: anxiety about death. One patient we spoke with
had the very terrifying and unfortunate experience of watching as a
woman who was sitting across from him at dialysis went into cardiac
arrest. Sadly, he witnessed her death. And of course, one of the first
thoughts to cross his mind was, “That could be me. I could die.”
And that was an extremely frightening thought. It shook him to his
core. His experience that day was extreme and unusual, but even
without having such a jarring experience you too may be growing
anxious over the thought that dialysis has brought you a bit closer to
your mortality. Before dialysis, you might have thought you were in-
vincible (although in reality you weren’t) and now you know you are
not. “True, now that you are on dialysis, statistically speaking, your
chances of dying are greater than they were before your kidneys
failed and you needed dialysis.” There we have said it: you may die.
Dwelling on this fact can be paralyzing and unhealthy. Now it is time
to move on. The good news about facing your mortality is that once
you realize you won’t be on this earth forever you may actually
appreciate certain aspects of life more than you ever did before dial-
ysis. However, becoming accustomed to this new level of awareness
can and does often heighten levels of anxiety.
Dialysis patients are often anxious about death, but this is not the
only common cause of anxiety. Many times they are anxious about
the actual dialysis process itself; they are afraid of the needles, of see-
ing their blood outside their body, of feeling pain, of sitting among
other patients who are significantly sicker than they, wondering if the
treatment actually will work as intended. Feeling acutely anxious
about all of the above is normal—for a time—but human beings are
remarkably adaptable. As the novelty of dialysis wears off, you
should become increasingly comfortable with what goes on inside
the clinic and the patients who frequent the clinic. No one wants to
get used to dialysis, but many people do. Or at least they do enough
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http://ebookcentral.proquest.com/lib/leicester/
Offer, Daniel, et al. Dialysis Without Fear : A Guide to Living Well on Dialysis for Patients and Their
Families, Oxford University Press, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/leicester/
Created from leicester on 2020-11-08 23:22:36.
124 D i a l y s i s w i t h o u t F e a r
to muddle through while taking ample pleasures from life. However,
if feelings of anxiety persist indefinitely, it may be time for you to
seek out additional sources of assistance. We’ll discuss these re-
sources shortly.
Now that you are dependent on dialysis to live, you may also be-
come anxious about what would happen to you in the event of a nat-
ural or terror disaster. Of course, it is not likely that you’ll ever have to
deal with either of these happenings, but even so, this is not an un-
reasonable fear to have. In times of crisis basic needs must be met. For
most people, their basic needs are food, water, shelter, clothing, and
medical care. For someone on dialysis, being able to access electricity
or supplies for peritoneal or home hemodialysis or a hemodialysis
center is another basic need that must be met. As you listen to the
world news and hear of the latest natural disaster it is normal to
think, “What would happen if the power were to go out, the roads
were to be washed out, or I was to be snowed in? What would happen
to me, if I could not get to the clinic or perform my own dialysis? How
long could I survive without dialysis?” These thoughts are scary, and
while we can find comfort by being prepared for emergencies (see
Chapter 10 regarding travel and emergency preparations), we can still
get worked up and nervous by constantly imagining doomsday
scenarios.
These types of “what if ” questions bring us to another common
source of anxiety: a fear of losing control. Many of us like to have a
sense of control over our lives, days, actions. We think that by mak-
ing lists, schedules, plans, routines, or goals we can influence the
course of our lives. This may be so, but there are also events we can-
not control that impact us profoundly. Going on dialysis is one such
event. Losing this real or perceived sense of control is often the pri-
mary anxiety trigger for many individuals. For people who demand
control, the best course of action is to gain knowledge and under-
standing and in some cases even pursue a modality that allows for
greater self-management and care.
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http://ebookcentral.proquest.com/lib/leicester/
Offer, Daniel, et al. Dialysis Without Fear : A Guide to Living Well on Dialysis for Patients and Their
Families, Oxford University Press, Incorporated, 2007. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/leicester/
Created from leicester on 2020-11-08 23:22:36.
Dealing with Emotions 125
Last, many individuals experience worry and anxiety about how
and if they will be able to continue to work and be a provider for
their family. Financial concerns are a huge source of anxiety for many
dialysis patients. Or, as we saw with Jeffrey, some people may be
anxious about how dialysis will affect their family not just finan- cially
but emotionally as well. This sense of concern and responsibil- ity for
the well-being of their loved …
Hemodialysis International 2017; 21:557–565
Original Article
Pediatrics
Psychosocial aspects of children and
families treated with hemodialysis
Anna MEDYN, SKA,1 Danuta ZWOLIN, SKA,1 Ryszard GRENDA,2
Monika MIKLASZEWSKA,3 Maria SZCZEPAN, SKA,4 Agnieszka URZYKOWSKA,2
Katarzyna ZACHWIEJA,3 Katarzyna KILIS,-PSTRUSIN, SKA1
1
Department of Pediatric Nephrology, Wroclaw Medical University, Wroclaw, Poland;
2
Department of
Nephrology, Kidney Transplantation and Hypertension, Children’s Memorial Health Institute, Warsaw,
Poland;
3
Polish-American Children’s Hospital, Jagiellonian University, Krakow, Poland;
4
Clinic of
Pediatrics, Nephrology and Endocrinology, Silesian Medical University, Zabrze, Poland
Abstract
Introduction: The aim of this study was to analyze the selected psychosocial aspects of chronic
kidney disease in children treated with hemodialysis (HD).
Methods: The study included 25 children treated with HD aged 2 to 18 years and their parents. Data
concerning the illness and socio-demographic parameters was collected. We used the Paediatric Quali-
ty of Life Inventory (PedsQL) for patients and for their parents the PedsQL-proxy version, General
Health Questionnaire (GHQ-12), Berlin Social Support Scales (BSSS), and the Caregivers Burden Scale
(CBS) to evaluate health-related quality of life (QoL) of HD children and their primary caregivers.
Findings: In the PedsQL test, the QoL of HD children was lower than in healthy children. Children
treated with HD assessed their QoL on the PedsQL questionnaire higher than the primary care-
givers, on all subscales as well as an overall health-related QoL. Scoring below 2 on the GHQ-12
test was reported in 56% of mothers, which may indicate that psychological symptoms have inten-
sified. There was no correlation between BSSS, CBS, and GHQ-12.
Discussion: The assessment of QoL in pediatric patients would allow for the earliest possible
identification of their nonsomatic problems and irregularities. This could, consequently, contribute
to improving QoL in both children with chronic kidney disease and their families.
Key words: Children, hemodialysis, quality of life, parents’ perceived burdens
Correspondence to: A. Medyn,ska, MD, PhD, Department
of Pediatric Nephrology, Wroclaw Medical University, Ul.
Borowska 213; 50-556 Wrocław, Poland. E-mail: anna.
[email protected]
Conflict of Interest: The authors declare that they have no con-
flict of interest.
Disclosure of grants or other funding: None
Ethical approval: All procedures performed in studies involv-
ing human participants were in accordance with the ethical
standards of the institutional and/or national research com-
mittee and with the 1964 Helsinki declaration and its later
amendments or comparable ethical standards.
Informed consent: Informed consent was obtained from all
individual participants included in the study.
VC 2017 International Society for Hemodialysis
DOI:10.1111/hdi.12526
INTRODUCTION
Today, owing to advances in the area of dialysis treatment
as well as in other medical procedures, children with
chronic kidney disease (CKD) have a significantly longer
survival rate. However, despite being provided with an
increasingly effective treatment, they can never be cured,
notwithstanding successful kidney transplantation.1 Con-
sequently, proper care over pediatric patients with CKD
must combine both medical and psychosocial aspects.
Already in 1994, Kurtin et al. stated that treating children
with CKD cannot be successful if it is narrowed only to
improving the mortality and/or comorbid conditions of
557
mailto:[email protected]
Medyn,ska et al.
558 Hemodialysis International 2017; 21:557–565
the disease.2 According to these authors, physical devel-
opment and achieving the same or similar general condi-
tion as healthy peers (with regard to school life, contacts
with peers, hobbies, and so forth.) should be also taken
into consideration.
Every chronic disease changes family functioning. It
increases stress levels and burdens the family members.
Moreover, it may influence family relationships. Besides,
being diagnosed with a chronic disease greatly increases
children’s dependency on parents/caregivers. As a conse-
quence, caregivers (usually mothers), face new problems
associated with caring for an ill child.
The chosen method of renal replacement therapy (RRT)
impacts both patients’ and their family’s quality of life
(QoL). Watson et al. reported that 34% of children began
RRT from HD or hemodiafiltration, and HD constitutes the
main therapeutic option for children aged 10–18 years.3
Schipper recognizes health-related quality of life
(HRQoL) as effects of chronic disease and its treatment
perceived by patients. This feeling is always subjective
and therefore difficult to assess. A study conducted in the
United States among 2500 children with chronic diseases
showed that patients with ESRD had significantly worse
HRQoL scores compared to children with other diseases.4
Polish studies proved that school-aged children with
chronic diseases assess their QoL remarkably worse com-
pared to healthy peers.5
QoL in HD patients has been assessed many times
before, but mainly in adults. QoL in children treated with
repeated hemodialysis has been assessed only in individual
studies. According to Glazebrook et al., 20% of CKD chil-
dren have a probable psychiatric disorder.6 Kogan et al.
reported that 30% of patients with CKD aged 9–18 years
fulfill the criteria for depression.7 The results published so
far do not allow for formulating recommendations regard-
ing psychological effects on HD patients and their families.
The assessment of QoL in pediatric patients would
allow identifying nonsomatic problems and irregularities
as soon as possible, which could contribute to improving
QoL in CKD pediatric patients and their families. Con-
cerning above mentioned remarks, we have conducted a
multicenter national study evaluating HRQoL in pediatric
patients treated with repeated HD and their families. Such
study has never been carried out in the Polish population.
MATERIAL AND METHODS
Eleven out of 12 pediatric dialysis centers in Poland par-
ticipated in the cross-sectional national study. The study
was conducted on HD children and their parent-proxies
between September 2011 and January 2012. The study
protocol adhered to the Declaration of Helsinki. The study
was approved by the Ethics Committee of Wroclaw
Medical University prior to study initiation. We obtained
written informed consent from all patients over 16 years
of age and all parents of all participants before their
enrollment in the study. Verbal consent was obtained from
patients under 16 years of age where possible.
The inclusion criteria for children were as follows: CKD
diagnosed at least 12 months prior to the study, HD treat-
ment at least 3 months prior to the study, age 2 or older, and
informed consent. All dialysis patients were without acute
illnesses and in stable psychophysical condition at the time
of the study. Patients with known history of severe to
profound mental retardation, renal, other solid-organ, bone
marrow, or stem cell transplantation, cancer/leukemia
diagnosis, and hospitalization within 14 last days (exclud-
ing hospitalization due to HD because of other reasons than
HD session), a significant life event unrelated to their
kidney disease in the past 30 days, such as losing a family
member were excluded.
Methods
Medical files were analyzed to obtain the following data:
primary diagnosis of kidney disease, patient’s age at the
time of CKD diagnosis, duration of illness, HD duration,
duration of nephrology care, additional non-renal comor-
bidities, place of living and its distance from a nephrologi-
cal center, and family history. Additionally, school-age
children and their parents were asked about schooling
level and special education requirements (supplementary
tutoring or an individualized education program). Then,
both parents were invited to fill out questionnaires
regarding changes in their families after the child’s CKD
diagnosis and their relationship with the people in their
immediate surroundings. The questionnaires were com-
pleted on a visit to the renal center and each parent filled
out the questionnaire individually.
In the next step, we used Paediatric Quality of Life
Inventory (PedsQL) 4.0 Generic Core Scales.8,9 We
obtained the user agreement from Mapy Research Insti-
tute in Lyon, France. In addition, the parents underwent
the following tests: the 12-item General Health Question-
naire (GHQ-12),10 Berlin Social Support Scales
(BSSS),11,12 and the Caregiver’s Burden Scale (CBS).13 All
tests were translated and validated in Poland.14–16 Cron-
bach‘s a for GHQ-12 is 0.72 and for the four subscales of
BSSS ranges from 0.70 to 0.86. Cronbach‘s a is 0.88 for
the total scale of CBS and ranges from 0.74 to 0.82 for the
subscales. The tests used in the study were thoroughly
presented in our other work.17 All tests were designed
Children in hemodialysis
559 Hemodialysis International 2017; 21:557–565
Gender
(or home-classes) median (quartiles)
HD 5 hemodialysis; CKD 5 chronic kidney disease.
aIn the past 6 months.
according to the general protocol and administration
guidelines.
Statistical analyses
Statistical analyses were performed using R for Windows,
version 2.15.1 (The R Foundation for Statistical Comput-
ing, Vienna, Austria) and MedCalc for Windows, version
12.3.1.0 (MedCalc Software, Mariakerke, Belgium).
Medians, quartiles, frequencies and percentages were
reported to describe the data, as appropriate. Qualitative
analyses were conducted using a chi-square test or Fish-
er’s exact test. Quantitative variables were tested for nor-
mality distribution by a Kolmogorov–Smirnov test. For
comparison between groups, the Mann–Whitney test and
the Kruskal–Wallis test were used, as appropriate.
Spearman’s correlation analysis was used to determine the
correlation between parameters. A P value of less than
0.05 was considered statistically significant.
RESULTS
The analysis included test results received from 25 children
treated with repeated HD and 25 mothers—patients’ prima-
ry caregivers. The study did not include test results gathered
from fathers/patients’ second caregivers because of insuffi-
cient sample size (only 6 fathers submitted filled tests).
Survey results
The characteristics of the studied group of patients are
presented in Table 1. All patients, except for 3 children
Table 1 Basic characteristic of hemodialysis children
Parameter n 5 25 %
Age, mean 6 SD, years 13.15 6 4.58
Children< 5 3 12
5 22 88
Female 15 60.0
Male 10 40.0
Cause of CKD
Chronic glomerulonephritis 2 8
Anomaly of kidney and urinary tract and chronic pyelonephritis 11 44
Hereditary kidney disease 2 8
Others 9 36
Unknown cause 1 4
Comorbidity
Yes 3 12
No 22 88
Family renal history
Yes 2 8
No 23 92
Place of residence (size)
Village or town < 50,000 residents 19 76
Town 50,000 – 100,000 residents 0 0
Town > 100,000 residents 6 14
Age at CKD diagnosis, median (quartiles), years 4.0 (1–10)
CKD duration, median (quartiles), years 7.5 (3.0–13.84)
Nephrological care duration, median (quartiles), years 6.04 (2.25–11.5)
HD therapy, median (quartiles), years 4 (3.75–4.0)
Distance from nephrology centre, median (quartiles), km
Number of hospitalizationsa median (quartiles)
59.0 (28.75–72.5)
2 (1–4)
The number of missed school-days in the past 6 months 8 (8–32)
Medyn,ska et al.
560 Hemodialysis International 2017; 21:557–565
Table 2 Basic characteristics of parents and families of
hemodialysis children
Parameter n %
Mothers 25 100
Age, mean 6 SD, years 37.96 6 6.74
Mother's education level
Elementary/trade school 16 64
High school 6 24
University degree 3 12
Employment
diagnosis according to patients’ mothers are presented in
Table 3. In the majority of families (52%), the financial
situation has changed; in 44% of cases the situation got
worse. Besides, in 44% of cases mothers declared deterio-
ration of their social contacts.
Test results
The results of PedsQL were lower in the group of HD
children compared to healthy children described in the
literature, both in terms of overall HRQoL (50.54 6 7.82
vs. 82.87 6 13.6) and in individual domains: physical
Table 3 Changes in the family observed by the mothers
after chronic kidney disease diagnosis in the child
Mothers’
evaluation
n 5 25
Yes No
Employment n %
n %
Yes 20 80 Change of location of residence 1 4 24 96
No 5 20 Changes made to current residence 3 12 22 88
Healthy Change in financial status 13 52 12 48
Yes 23 92 Deterioration 11 44
No 2 8 Improvement 2 8
Family
Full
19
76
The change of the source of income
Caring for the child
5 20 20 80
Single-parent family 6 24 Mother 19
Sibling Father 0
Yes 24 94 Both parents 6
No 1 4 Participation of other people 9 36 16 64
in child care
under the age of 5 years, were subjected to compulsory
schooling (22 patients—88%). The majority of patients
were home-schooled (15 children—68%), the remaining
children attended classes in school (7–32%). Nine pupils
(36%) required no help with their studying; the remain-
ing 16 children (64%) received assistance from their
parents.
The characteristics of HD patients’ families are pre-
sented in Table 2. Most children were brought up in full
families; only 6 patients had only one parent (a mother).
Almost all children had siblings, only one was an only
child.
The primary caregivers of patients were mothers (in 19
cases), and both parents (in 6 cases). In 9 cases (36%),
additional family members assisted with a care for a sick
child, and they were usually patients’ grandparents. Dif-
ferences that have occurred in families after disease
Changes in relations among children 4 16 21 84
Improvement 4 16
Deterioration 0 0
Changes in social contacts 11 44 14 56
Improvement 0 0
Deterioration 11 44
New friendship 12 48 13 52
Yes 8 32
No 17 68
Healthy
Yes 23 92
No 2 8
Fathers 25 100
Age (mean 6 SD), years 40.92 6 7.42
Father's education level
Elementary/trade school 20 80
High school 2 8
University degree 3 12
Grandparents 7 28
Siblings 1 4
Cousins 1 4
Changes in attitude toward
the ill child
6 24 19 76
Improvement 6 24
Deterioration 0 0
Changes in attitude toward 2 8 23 92
other children
Improvement 1 4
Deterioration 1 4
Children in hemodialysis
561 Hemodialysis International 2017; 21:557–565
Table 4 PedsQL 4.0 generic core scales from child’s self-report (for ages 5–18; n 5 25) and parent-proxy report—primary
caregivers
HD children Primary caregivers of HD children
Characteristic n 5 25 n 5 25
Physical functioning 40.63 (18.75–65.63) 51.56 (20.31–68.75)
Emotional functioning 52.5 (35.0–75.0) 50.0 (37.5–65.0)
Social functioning 67.5 (50.0–80.0) 62.5 (45.0–85.0)
School functioning 47.5 (35.0–65.0) 40.0 (35.0–60.0)
Overall HRQoL 50.54 (40.22–64.13) 49.46 (40.22–62.5)
The data are presented as a median and quartiles (first–third quartile).
HD 5 hemodialysis; HRQoL 5 health-related quality of life.
functioning (40.63 6 6.46 vs. 86.86 6 13.88) emotional
functioning (52.5 6 10.42 vs. 78.21 6 18.64), social
functioning (67.5 6 11.46 vs. 84.04 6 17.43), school
functioning (47.5 6 9.46 vs. 79.92 6 16.93).8
The test results regarding the evaluation of QoL in HD
children by their primary caregivers were lower in all
domains compared to caregivers of healthy children
(physical functioning: 51.56 6 10.24 vs. 83.26 6 19.98,
emotional functioning: 50.0 6 9.83 vs. 80.28 6 16.99,
social functioning: 62.5 6 12.25 vs 82.15 6 20.08 and
school functioning: 40.0 6 9.36 vs 76.91 6 20.08) and
overall (49.46 6 9.46 vs. 81.34 6 15.92). Functioning in
the physical domain was assessed higher by caregivers
than by children, but in other domains the caregivers’
evaluation of QoL was lower than children’s assessment.
The results of PedsQL tests in HD children and their pri-
mary caregivers are presented in Table 4.
The results of CBS, BSSS, and GHQ-12 tests received
from HD children’s primary caregivers are presented in Table
5. The overall level of burden on the CBS scale was
2.39 (1.77–2.57) that means “medium burden.” On the sub-
scales we noted low levels regarding the emotional involve-
ment and the environment, whereas the other parameters
were medium. The highest score was reported on the sub-
scale “disappointment.” The average value equaled 2.6, but
such result does not indicate high levels of burden.
The level of social support assessed by primary care-
givers varied from 2.78 to 3.5 on individual scales. The
lowest scoring concerned “the need for support” and the
highest “perceived available information support”—3.75.
In the GHQ-12 test the average score was 3. The higher
values indicated more psychological symptoms. Score
above 2 points, which indicated the possible occurrence
education, professional career, the family structure (com-
plete/single parent), having or not having other children,
and the source of income (professional career vs. welfare
benefits). There was no correlation between scoring on all
scales and the hometown population size, and between
CBS results and CKD duration.
A statistically significant negative correlation was found
between PedsQL parent-proxy (overall HRQoL) and CBS:
total burden index, environment, disappointment and
general strain (r 5 20.55, P 5 0.006; r 5 20.74,
P < 0.001; r 5 20.42, P 5 0.045; r 5 20.45, P 5 0.03,
Table 5 Berlin Social Support Scale, Caregiver Burden
Scale, and General Health Questionnaire test results
among the mothers (primary caregivers) of hemodialysis
children
Berlin Social Support Scale (BSSS)
Perceived available support:
Emotional 3.50 (2.63–4.00)
Instrumental 3.75 (2.88–3.75)
Need for support 2.78 (2.50–3.25)
Support seeking 2.90 (2.40–3.38)
Actually received support:
Emotional 2.80 (2.60–3.00)
Informational 3.20 (2.70–3.40)
Instrumental 3.60 (3.00–4.00)
Caregiver Burden Scale (CBS)
General strain 2.38 (1.88–2.69)
Social isolation 2.17 (1.33–3.00)
Disappointment 2.6 (2.3–2.9)
Emotional involvement 1.67 (1.33–2.17)
Environment 1.67 (1.5–2.25)
Total burden index 2.39 (1.77–2.57)
of abnormal mental functioning, was observed in 14
(56%) of mothers.
General Health Questionnaire
(GHQ-12)
3 (2–5)
There was no significant correlation between BSSS,
CBS and GHQ-12 results and the parents’ age, their
The data are presented as a median and quartiles (first–third
quartile).
Medyn,ska et al.
562 Hemodialysis International 2017; 21:557–565
respectively). Positive correlation between BSSS subscale:
perceived available emotional support and PedsQL
parent-proxy were observed (emotional functioning r
5 0.46, P 5 0.03 and social functioning r 5 0.52, P
5 0.01). We did not note any correlation between
GHO-12 and PedsQL parent-proxy.
DISCUSSION
Our research comprehensively assessed the psychosocial
situation of HD pediatric patients. The HRQoL was
assessed both by HD children and by their parents. More-
over, we studied selected aspects of parents’ psycho-social
functioning when facing child’s illness.
The studies that evaluate QoL in children undergoing
RRT are relatively few and they usually involve small
groups of patients treated with various methods. In the
available literature, QoL was compared in CKD children
on different stages (predialysis vs. RRT) or undergoing
various methods of RRT (HD, peritoneal dialysis-PD,
transplantation-Tx).18–26 In some of the above-mentioned
studies the authors analyzed QoL in children on dialysis
(both PD and HD), whereas the type of dialysis also influ-
ences QoL.27,28 The available literature lacks a study car-
ried out both on children undergoing repeated
hemodialysis and on their caregivers.
We have demonstrated that HD children assessed their
HRQoL (in the overall assessment and in all QoL
domains) worse than general population of healthy chil-
dren. In our study the patients provided the lowest scores
on the subscale “physical functioning,” which can be
associated with the fact that both disease itself and the
therapy lead to numerous changes in children’s appear-
ance. The patients’ appearances such as short height or
bone deformities, which appear most of all during the
puberty period, are a significant element of self-
acceptance. Riano-Galan et al. reported that patients’
height itself constitutes an independent indicator of
health-related satisfaction.25
We also received very low results on the subscale
“school functioning” which may partly result from the
method of treatment itself. Transportations and many
hours in hospitals make difficult or even impossible to
integrate with school peers. Transportation and many
hours spending in hospital may be the reasons for leaving
lessons and learning difficulties. Another factor contribut-
ing to the scoring on the subscale “school functioning”
may be a due to disorders associated with the impact of
HD on the patients’ central nervous system (declines in
blood pressure, anemia, and disturbances in acid-base and
calcium-phosphate balances). Our patients provided
the highest scores on the subscale “social functioning,”
although the scoring was lower than in healthy children.
The above results may be connected with the use of
defense mechanisms or with narrow the perceived group
of peers only to the closest environment.
Similarly to our study, Goldstein et al. reported that
children with ESRD (among them 32 HD children) pre-
sent a significantly lower HRQoL compared to healthy
peers both in the overall scoring and on all subscales.26
Lopes et al., having adopted the same research instru-
ment, presented comparable results. Dialysis patients
(including 25 children, 12 of them treated with HD)
assessed their QoL lower in the physical, social, and
school functioning domains compared to healthy peers.19
Moreover, other researchers having adopted different
research instruments, reported lower QoL compared to
the control group.18,22,23,25 Heath et al. presented differ-
ent results. They reported that children with CKD (n
5 124, including 8 children with HD) have significant- ly
higher QoL than the general population.21 Maxwell et
al. reported that children with CKD have significantly
higher QoL compared to healthy population, but it partic-
ularly concerned males.20 The authors suggest that HD
children “live with the disease” and have lower life
expectations since they accept their reality as it is.
Both parents and children assess the same situation
according to individual standards. In our study, the pri-
mary caregivers assessed QoL of their children lower on
all subscales and overall compared to the healthy group
described in the literature, which is in accordance with
many other authors’ reports.22,24 The diagnosis of chronic
disease in child significantly changes caregivers assess-
ment of children’s lives and possibilities. Our study
showed that primary caregivers assessed QoL lower than
children in overall and on all subscales without regarding
physical functioning. Similar results were also presented
by other researchers such as Goldstein et al., Park et al.,
and McKenna et al., who emphasized this fact particularly
clearly in children on dialyses.22,24,26 Such an attitude may
consequently lead to a situation in which parents become
“over-protective,” children are not self-reliant, but they
dependent on their caregivers. On the other hand, Lopes
et al. presented different results.19 According to these
authors, primary caregivers assessed QoL higher than
patients in all areas except for school functioning. The
discrepancy between patients and caregivers was sig-
nificantly higher than in the control group (a child—a
parent). The older the child, the differences in assessing
QoL were higher. Such discrepancies may lead, particu-
larly during the adolescence, when a need to become
Children in hemodialysis
563 Hemodialysis International 2017; 21:557–565
independent is strong, to isolation, psychological imbal-
ances and, consequently, to noncompliance.
It should be emphasized that children with ESRD and
their parents present similar HRQoL as children with
newly-diagnosed cancer and those undergoing chemo-
therapy and radiotherapy treatments.29 Therefore, it must
be concluded that having a child with CKD in a family is
a very difficult experience, not always sufficiently
acknowledged both by the medical personnel and by the
surrounding environment. What is more, it suggests that
there is a need of monitoring and providing such patients
with ongoing psychological care.
The socio-economic situation of Polish families with
children treated with repeated HD appears to be difficult.
In the examined families, 68% of mothers did not work.
We associated this primarily with the fact that mothers
devoted their time to care over ill children, transporting
them to dialysis center as well as subsequent, several-
hour stays in hospital during the treatment itself. In Poland
commuting to nephrology centers is troublesome since
transportation, due to financial reasons, cannot be
individualized, and it often involves travelling long distan-
ces, which is very time-consuming. Besides, 20% of our
patients’ fathers were unemployed. Following the disease
diagnosis, 52% of mothers observed that the financial sit-
uation of their families had deteriorated. According to the
data from the Polish Central Statistical Office (2013), chil-
dren with chronic illnesses constitute only 5.5% of all
children that receive social assistance. Marciano et al.
observed that a difficult socio-economic situation in fami-
lies with children with CKD was not correlated with low-
er HRQoL.18 Adversely, von Rueded et al. stated that low
economic status may lower HRQoL.30 In our study, we did
not directly study the relationship between the above-
mentioned factors, but taking into consideration the
reported decline in the economic situation, it can be stat-
ed that this tendency seems highly probable.
All children subject to compulsory schooling participat-
ed in classes. In our study the vast majority of children (15
children, i.e., 68%) were home-schooled. Buyan et al.
reported that 50% of dialyzed children (including HD and
PD) leave school.23 In the American study, 53% of
children were able to successfully achieve full-time school
attendance.31 School prepares children for adult life,
allows their independence from parents and serves as a
best indicator of socializing children with chronic ill-
ness.32 Therefore, it is especially essential for HD children
to ensure their optimal educational opportunities suited to
the RRT.
The present study demonstrated that according to CB
scale, the overall burden of primary caregivers was at the
medium level. Therefore, contrary to the expected results,
it was not high. Perhaps being primary caregivers leads to
the satisfaction with the care they can provide. We
recorded the highest values of burden on the subscale
“disappointment.” This may result from the fact that
mothers, because of relentless care they provide, had
abandoned their own plans and dedicated themselves to
the ill child. We also observed an excessive burden on the
subscale “the overall effort,” which probably resulted
from the physical and mental fatigue and from the sense
of responsibility for an ill child. This seems even more sig-
nificant in view of the fact that only 1/3 of mothers/care-
givers stated that they receive help from other people so
that they are most exposed to an excessive burden.
The GHQ-12 can determine mental health, experienced
distress, and identify people who are likely to develop
mental health problems. In our study, more than half of
the patients’ mothers received the score …
Pediatr Nephrol (2013) 28:2157–2167
DOI 10.1007/s00467-013-2532-6
Psychosocial aspects of children and families of children
treated with automated peritoneal dialysis
Katarzyna Kiliś-Pstrusińska & Anna Wasilewska & Anna Medyńska &
Irena Bałasz-Chmielewska & Ryszard Grenda & Agnieszka Kluska-Jóźwiak &
Beata Leszczyńska & Ilona Olszak-Szot & Monika Miklaszewska & Maria Szczepańska &
Marcin Tkaczyk & Agnieszka Tkaczyk & Katarzyna Zachwieja & Maria Zajączkowska & Helena
Ziółkowska & Ilona Zagożdżon & Danuta Zwolińska
Received: 28 January 2013 / Revised: 21 May 2013 / Accepted: 31 May 2013 / Published online: 16 August 2013
# The Author(s) 2013. This article is published with open access at Springerlink.com
Abstract
Background The aim of this study was to analyze psycho-
social aspects of chronic kidney disease (CKD) in children
treated with automated peritoneal dialysis (APD).
Methods The study assessed 41 children > 2 (range 2.1–18)
years of age and their parents. Data concerning the illness
and sociodemographic parameters were collected. Patients
completed the Paediatric Quality of Life Inventory (PedsQL)
and their parents the PedsQL-proxy version, General Health
Questionnaire (GHQ-12), Berlin Social Support Scales
(BSSS), and Caregiver’s Burden Scale (CBS).
Results Parents rated their children’s overall health-related
quality of life (QoL) as well as their physical and emotional
functioning lower than the patients themselves. The majority
of primary caregivers had a medium level of the total burden
index in the CBS and higher values in the scales need for
support and perceived available support than in the received
support (BSSS). In the GHQ-12, 51.2 % of primary care-
givers had scores >2 points, which indicated the possible
occurrence of abnormal mental functioning.
Conclusions Financial support for patients’ families is nec-
essary. Parents who provide primary care to children on PD
require, above all, emotional support and assistance in self-
fulfilment. More than half of them may have impaired men-
tal function. There is the strong need to provide continuous
psychological care for caregivers. Differences in perception
K. Kiliś-Pstrusińska (*) : A. Medyńska : D. Zwolińska
Department of Paediatric Nephrology, Wrocław Medical
University, ul. Borowska 213, 50-556 Wrocław, Poland
e-mail: [email protected]
A. Wasilewska
Department of Paediatrics and Nephrology,
Medical University of Białystok, Białystok, Poland
I. Bałasz-Chmielewska : I. Zagożdżon
Department of Paediatric & Adolescent Nephrology &
Hypertension, Medical University of Gdansk, Gdansk, Poland
R. Grenda : A. Urzykowska
Department of Nephrology, Kidney Transplantation and
Hypertension, Children’s Memorial Health Institute,
Warsaw, Poland
A. Kluska-Jóźwiak
Department of Paediatric Cardiology and Nephrology,
Poznan University of Medical Sciences, Poznan, Poland
B. Leszczyńska : H. Ziółkowska
Department of Paediatrics and Nephrology,
Medical University of Warsaw, Warsaw, Poland
I. Olszak-Szot
Department of Nephrology, Children Hospital, Toruń, Poland
M. Miklaszewska : K. Zachwieja
Polish-American Children’s Hospital, Jagiellonian University,
Krakow, Poland
M. Szczepańska
Clinic of Paediatrics, Nephrology and Endocrinology,
Silesian Medical University, Zabrze, Poland
M. Tkaczyk
Nephrology Division, Polish Mothers’ Memorial Hospital
Research Institute, Łodź, Poland
M. Zajączkowska
Department of Paediatric Nephrology, Medical University
of Lublin, Lublin, Poland
ORIGINAL ARTICLE
mailto:katarzyna.kilis-pstrusins[email protected]
2158 Pediatr Nephrol (2013) 28:2157–2167
of the children’s activity in varied areas by the patients
themselves and their caregivers may contribute to further
problems within families.
Keywords Children . Peritoneal dialysis . Health-related
quality of life . Parents’ perceived burdens . Primary
caregivers
Introduction
Home peritoneal dialysis (PD) is the preferred chronic dialysis
modality for children with end-stage renal disease (ESRD) [1].
Thanks to technological advances, inter alia, various PD
regimens and solutions, as well as clinical experience, patient
survival and somatic condition has improved [1, 2]. Never-
theless, impaired health-related quality of life (HRQoL)
among patients on dialysis remains a challenge [3]. Patient’s
QoL is closely related to the family, especially when the
patient is on PD. In addition to the typical parental responsi-
bilities and activities of providing support, parents must also
be engaged in the therapeutic process [4, 5]. In many cases,
the home environment is medicalized, with family members
becoming the main caregivers burdened with many responsi-
bilities related to PD and thus affects the life of the patient’s
family. On the other hand, each parent’s perception of their
psychosocial situation, as well as their reaction to it, may
affect the relationship between parents and their children and
the child’s functioning [6, 7].
Before the decision concerning renal replacement treatment
(RRT) is made, it is necessary to assess the family’s social,
psychological, and economic background and recognize the
needs of parents/caregivers [2, 8]. Disregarding those factors
creates the risk of complicating the method. Thus far, psycho-
social aspects of children with chronic kidney disease (CKD)
treated with automated peritoneal dialysis (APD) have rarely
been analyzed, and never in Poland. Therefore, we conducted a
multicenter national study with the aim of analyzing the
psychosocial situation in families of children treated with
APD. We gave particular attention to parents’ perceived
burdens. We considered children’s HRQoL as perceived by
themselves and as by their parents, because perceiving the
QoL of sick children is one element of assessing the family
situation. Another aim was to determine in which areas of
everyday life the families of children treated with APD require
support.
Methods
Eleven of 12 pediatric dialysis centers in Poland participated
in the cross-sectional national study. The research was
conducted on children with ESRD treated with APD and their
parent–proxies between September and December 2011. The
study protocol adhered to the Declaration of Helsinki and was
approved by the Ethics Committee of Wrocław Medical
University. Written informed consent was obtained from all
participants >16 years of age and all parents before enrollment
in the study. Verbal consent was obtained from patients <16 years
where possible. Inclusion criteria for children were as follows:
1. CKD diagnosed at least 12 months prior to the study,
2. PD beginning at least 3 months prior to the study,
3. age ≥2 years, and
4. informed consent.
Exclusion criteria for children comprised:
1. a history of severe to profound mental retardation,
2. renal, other solid-organ, bone marrow, or stem cell
transplantation,
3. cancer/leukemia diagnosis,
4. hospitalization within 14 days (excluding hospitalization
due to peritoneal dialysis control visit), and
5. a significant life event unrelated to their kidney disease
in the past 30 days, such as losing a family member.
In Poland, there is a common treatment protocol for
managing children on APD, with PD nurses who meet the
families predialysis. The nurses work in a dialysis center.
Home visits prior to dialysis are done by district nurses who
also do the follow-up visits. The district nurses are in constant
contact with the PD nurses. The PD family has access to
district social workers and psychologists.
Medical files were analyzed to obtain the following data:
primary diagnosis of kidney disease, patient’s age at time of
CKD diagnosis, illness duration, APD duration, nephrologic
care duration, additional nonrenal comorbidities, place of
living and distance from a nephrologic center, and family
history. Additionally, school-age children and their parents
were asked about schooling level and special education
requirements (supplementary tutoring or an individualized
education program). Then, both parents were invited to fill
out questionnaires regarding changes in their families after the
child’s CKD diagnosis and their relationship with the people
in their immediate surroundings. Questionnaires were
completed on a visit to the renal center, and each parent
filled out the questionnaire separately.
In the next step, we used Pediatric Quality of Life Inventory
(PedsQL) 4.0 Generic Core Scales [9, 10]. We obtained the user
agreement from Christelle Berne, Mapy Research Institute in
Lyon, France. In addition, parents underwent the following test
studies: the 12-item General Health Questionnaire (GHQ-12)
[11], Berlin Social Support Scales (BSSS) [12, 13], and the
Caregiver’s Burden Scale (CBS) [14]. All tests were translated
and validated in Poland [15–17]. Cronbach’s α for GHQ-12 is
0.72 and for the four subscales of BSSS ranges from 0.70 to
Pediatr Nephrol (2013) 28:2157–2167 2159
0.86. Cronbach’s α is 0.88 for the total scale of CBS and ranges
from 0.74 to 0.82 for the subscales.
The PedsQL assesses physical, emotional, social, and
school functioning in children and adolescents. The mea-
sure comprises a report from children 5–18 years of age and
a parent report for children between 2 and 18 years of age
regarding the child’s HRQoL. The PedsQL 4.0 Ge- neric
Core Scales were specifically designed to measure the core
health dimensions outlined by the World Health
Organization.
The GHQ-12 measures psychological distress and is used
to detect nonpsychotic psychiatric disorders such as depres-
sion or anxiety in adults [11]. The scale asks whether the
respondent has experienced a particular symptom or behav-
ior recently. Each item is rated on a four-point scale (less than
usual, no more than usual, rather more than usual, or much
more than usual). The GHQ-12 is brief, easy to complete,
and its application in research settings as a screening tool is
well documented. We used the original scoring method in
our study (response categories score: 0, 0, 1, and 1, respec-
tively). This produces scores ranging from 0 to 12; the higher
values indicate more psychological symptoms.
The original BSSS includes six independent subscales
(perceived available support, need for support, support seek-
ing, actual received support, provided support, and protective
buffering) and measures both the cognitive and behavioral
aspects of social support [12, 13]. With the authors’ consent,
four subscales were used for this study: perceived available
support (8 items), need for support (4 items), support seeking
(5 items), and actual received support (15 items). The per-
ceived support subscale comprises items of emotional and
instrumental support; the overall received support includes
items of emotional, instrumental, and informational support.
The response format is the same for all subscales. Individuals
rate their agreement with the statements on a four-point scale
[strongly disagree (1), somewhat disagree (2), somewhat
agree (3), and strongly agree (4)]. An average mean within
the range of 1–4 was calculated for each subscale. A higher
score indicated greater burden.
The CBS uses 22 items to assess the subjective burden of
caregivers to chronically ill individuals [14]. All items are
scored between 1 and 4 (not at all, seldom, sometimes, often)
and cover areas such as the caregiver’s health, feeling of
psychological well-being, relationships, social network,
physical workload, and environmental aspects that might
prove important. The scale was divided into five indices:
general strain (8 items), socialization (3 items), disappoint-
ment (5 items), emotional involvement (3 items), and envi-
ronment (3 items). The total burden index is the mean of all
22 items. The higher the score, the greater the burden. The
overall mean of a caregiver’s burden score was defined as
low burden (1.00–1.99), medium burden (2.00–2.99), and
high burden (3.00–4.00) [14].
All tests were designed according to the general protocol
and administration guidelines.
Statistical analyses
Statistical analyses were performed using R for Windows,
version 2.15.1 (The R Foundation for Statistical Computing,
Vienna, Austria) and MedCalc for Windows, version 12.3.1.0
(MedCalc Software, Mariakerke, Belgium). Medians,
quartiles, frequencies, and percentages were reported to
describe data, as appropriate. Qualitative analyses were
conducted using a chi-squared test or Fisher’s exact test.
Quantitative variables were tested for normality distribution
by a Kolmogorov–Smirnov test. For comparison between
groups, the Mann–Whitney and Kruskal–Wallis tests were
used, as appropriate. Spearman’s correlation analysis was
used to determine the correlation between parameters. A
p value <0.05 was considered statistically significant.
Results
Taking into consideration inclusion and exclusion criteria,
except for parents’ consent, 50 children were qualified for
inclusion in the study/examination. Final studies were
conducted among 41 children with APD whose parents gave
their consent. Among the 82 parents and/or their guardians
(all Polish), data from 40 mothers (one mother maintains no
contact with her sick child) and 39 fathers were analyzed.
Four fathers do not live with their families, but two mothers
provided the fathers’ information. In subsequent parts of the
analysis, only the results of fully completed surveys were
taken into consideration.
Survey results
Characteristics of the examined children are presented in
Table 1. All children at their compulsory school age (> 5
years, n =30) carried on their education. Thirteen children
(44.8 %) went to school (including two attending special
schools); 16 patients were home-schooled (55.2 %). One
child did not provide information with regard to the type of
learning. Eleven pupils (37.93 %) required no help with their
studying; the remaining 18 children (62.07 %) received
assistance from their parents. The number of school days (or
lesson days at home) missed in the previous 6 months was
(median, quartiles) 10 (0–30).
The characteristics of APD children’s families, their par-
ents in particular, are presented in Table 2. Most children
were growing up in complete families; only five of them
lived with one parent (four with the mother and one with the
father). Thirty children had siblings (26 of them one or two;
four had three to six). Family household incomes come from
2160 Pediatr Nephrol (2013) 28:2157–2167
Table 1 Basic characteristics of
automated peritoneal dialysis
(APD) children
Parameter Number= 41 Percentage
Age, mean ± SD, (years) 9.24± 5.09
Children <5 10 24.4
≥ 5 31 75.6
Gender
Female 14 34.15
Male 27 65.85
Cause of CKD
Chronic glomerulonephritis 13 31.71
Anomaly of kidney and urinary tract and chronic pyelonephritis 15 35.58
Hereditary kidney disease 9 21.95
Others 3 7.32
Unknown cause 1 2.44
Comorbidity
Yes 6 14.6
No 35 85.4
Family renal history
Yes 4 9.76
No 37 90.14
Place of residence (size)
Village or town <50,000 residents 27 65.85
Town 50,000–100,000 residents 3 7.32
Town > 100,000 residents 11 26.83
Age (years) at CKD diagnosis, median (quartiles), 1.5 (0.02–6.0)
CKD duration (years), median (quartiles) 4.17 (2.21–8.15)
Nephrological care duration (years), median (quartiles) 4.0 (2.25–8.18)
PD therapy (years), median (quartiles) 1.98 (0.71–2.25)
PD peritoneal dialysis; CKD Distance from nephrology center (km), median (quartiles) 65.0 (21.5–102.5)
chronic kidney disease Number of hospitalizationsa, median (quartiles) 6.0 (3.0–6.0)
a In the previous 6 months
various sources but mostly from professional careers, indi-
cated by 82.5 % of parents (multiple choice options). Other
sources of income included annuity and/or pension, which
were indicated by 15 % of parents, and social welfare in 47 %
of respondents. Parents’ perceived change in their families’
situation after the child’s CKD diagnosis is summarized in
Table 3. No statistically significant differences were found
with respect to the parents’ gender.
Use of social welfare and unemployment, and deterioration
in financial situation in parents’ evaluation (Tables 2 and 3)
showed a harsh economic situation for the family.
Each parent was asked to evaluate their relationships with
the people in their immediate surroundings and with medical
staff by assigning points from 1 (very bad) to 5 (very good).
Results are shown in Table 4. Differences between fathers’
and mothers’ assessments were not statistically significant.
In each family, parents indicated the sick child’s main care-
giver. The group of primary caregivers comprised 40
mothers and one father. Guardians (henceforth referred to as
primary caregivers) were asked to share their expectations
toward medical personnel. Twelve individuals (29.3 %)
described their expectations toward nurses. In addition to
general terms, such as “providing care” and “help”, attention
focused on the assistance provided during the hospital stay,
sharing more information regarding PD, greater
professionalism, and better contact with the child. With
respect to physicians, nine individuals (22 %) expected
“good care” and more detailed information about the
patient, mainly about the projected course of the disease
and their child’s future. Only 15 primary caregivers (36.59
%) asserted that their child’s kidney transplantation was
discussed.
Test results
The PedsQL test results in the entire group of parents who
provide primary care for APD children (n =41) were signif-
icantly lower in relation to results among parents of healthy
children published in the literature, both within the scope of
overall HRQoL (51.0 ±16.42 vs 81.34±15.92, p <0.01) and
Pediatr Nephrol (2013) 28:2157–2167 2161
Table 2 Basic characteristics of parents and families of children on
automated peritoneal dialysis
PedsQL test results among children between 5 and 18 years of
age (n=31) and both parents. All primary guardians and 13
“secondary parents” completed the tests. Both parents rated
their children’s physical and emotional functioning as well as
their overall HRQoL as significantly lower than the sick
children did themselves. The patients rated their social func-
tioning higher than did their primary caregivers. No signifi-
cant differences were found in the evaluation of school func-
tioning between the studied groups. The intraclass cor-
relation coefficient (ICC) between primary parent and child
reports was calculated to be 0.74. The ICC between secondary
parent and child reports and between primary and secondary
parent reports were calculated to be 0.68 and 0.64,
respectively.
Parents’ test results are demonstrated in Table 6. There
were no significant differences within the scope of social
support (perceived available support, the need for such sup-
port, support seeking, and received support) between prima-
ry and secondary parents (BSSS results). The CB scale
demonstrated that the average total burden index in primary
caregivers was medium. Results obtained also correspond
with medium burden in the following subscales: general
strain, social isolation, and disappointment. Low levels of
burden were observed in the emotional involvement and
environment subscales. The results in the secondary parents
group indicate lower general strain than in primary guard-
ians; no significant differences were demonstrated with re-
spect to the remaining subscales; however, the average total
burden index (2.0) borders on low and medium burden.
GHQ-12 results in the group of primary caregivers were
significantly higher than in the group of secondary care-
givers. In addition, scores >2 points, which indicated the
possible occurrence of abnormal mental functioning, were
observed in 51.2 % of primary parents and in only 23.53 %
of parents who did not provide primary care. There was no
SD standard deviation
a One mother does not live with her child (no contact). b Four fathers do not
live with their families, but in the case of two fathers, the mothers provided
their information. c No information was provided for two fathers
in individual subscales: physical functioning (49.24±18.75 vs
83.26±19.98, p<0.01), emotional functioning (55.12±18.5 vs
80.28±16.99, p<0.01), social functioning (55.24±22.11 vs
82.15±20.08, p<0.01), and school functioning (55.7±28.93 vs
76.91±20.08, p<0.01) [9]. Similarly, PedsQL test results among
APD patients (5–18 years of age) were significantly lower sta-
tistically (p<0.01) than in a group of healthy children: phys-
ical functioning (61.19±18.57 vs 86.86±13.88), emotional
functioning (66.29±14.08 vs 78.21±18.64), social function-
ing (69.19±22.11 vs 84.04±17.43), school functioning
(65.83±28.93 vs 79.92±16.93), and overall HRQoL
(65.83±28.93 vs 82.87±13.6) [9]. Table 5 summarizes the
significant correlation between BSSS, CBS, and GHQ-12
and parents’ age, education, professional career, family
structure (complete/single parent), having or not having oth-
er children, and source of income (professional career vs
welfare benefits). The level of general strain (CBS) declared
by women was significantly higher than that declared by
men (2.63, 1.91–3.0 vs 1.94, 1.75–2.75, p = 0.03). Guardians
who live in medium-sized cities demonstrated a higher level
of social isolation (3, 2.33–3.42) and total burden index
(2.59, 2.0–2.77) than residents in rural areas and in large
cities (social isolation 2.0, 1.33–2.75 and 2.33, 1.37–2.84,
respectively; p = 0.02; total burden index: 1.82, 1.58–2.48
and 2.16, 1.7–2.73, respectively; p= 0.01). No significant
differences were found between residents in rural areas and
large cities in this regard.
Perceived available instrumental support was lowest
among small-town residents (3.25, 2.19–4.0) in comparison
with village residents (3.75, 3.75–4) and city residents (4.0,
Parameter Number Percentage
Mothers 40a 100
Age, mean ± SD, (years) 28.16±6.0
Mother’s education level
Elementary/trade school 14 35
High school 15 37.5
University degree 11 27.5
Employment
Yes 29 72.5
No 11 27.5
Healthy
Yes 34 85
No 6 15
Fathers 39b 100
Age, mean ± SD, (years) 40.03±9.27
Father’s education level
Elementary/trade school 24 61.54
High school 7 17.95
University degree
Employmentc
8 20.51
Yes 30 81.1
No 7 18.9
Healthy
Yes 33 84.62
No 6 15.38
Family
Full 36 87.8
Single-parent 5 12.2
Sibling
Yes 30 73.17
No 11 26.83
2162 Pediatr Nephrol (2013) 28:2157–2167
Table 3 Changes in the family observed by the parents after chronic kidney disease (CKD) diagnosis in the child
Mothers’ evaluation n=40a Fathers’ evaluation n =35a P valued
Yes
No
Yes
No
n %
n %
n %
n %
Change of location of residence 3 7.5
37 92.5
1 2.86
34 97.14 0.61
Changes made to current residence 24 60 16 40 20 57.14 15 42.86 0.81
Change in financial status 16 40 24 60 16 45.71 19 54.29 0.64
Deterioration 16 40 16 45.71
Improvement 0 0
Change of income source 9 22.5 31 77.5 7 20 28 80 1
Caring for the child 0.14
Mother 34 85 24 68.57
Father 1 2.5 1 2.86
Both parents 5 12.5 10 28.57
Participation of other people in child care 22 55 18 45 18 51.34 17 48.57 0.81
Grandparents 18 15
Siblings 2 3
Cousins 2 0
Changes in attitude toward the ill child 15 37.5 25 62.5 9 25.71 26 74.29 0.32
Improvement 14 35.0 9 25.71
Deterioration 1 2.5 0
Changes in attitude toward other children b4 13.33 26 86.67 c4 16.0 21 84.0 1
Improvement 4 13.33 3 12
Deterioration 0 1 4
Changes in relations among children b10 33.33 20 66.67 c6 24 19 76 0.55
Improvement 9 30.0 6 24
Deterioration 1 3.33 0
Changes in social contacts 25 62.5 15 37.5 17 48.57 18 51.43 0.25
Improvement 1 2.5 0
Deterioration 24 60.0 17 48.57
New friendship 28 70 12 30 17 48.57 18 51.43 0.09
Data shown as a number of responses (percent)
a Data collected from 75 surveys (40 mothers, 35 fathers); missing surveys (7; 7.32 %): 4 fathers, 1 mother, who do not live in the same household; 2
fathers did not fill out this part of the survey
b n =30, c n =25; d differences between mothers’ and fathers’ groups, p value
Table 4 Evaluation of parents’ relationships with other people: 1 (very bad), 5 (very good)
Mother Father
n 1 2 3 4 5
n 1 2 3 4 5
Father/mother of the child 38 3 (7.9) 1 (2.6) 5 (13.2) 14 (36.8) 15 (39.5) 35 2 (5.7) 1 (2.9) 2 (5.7) 17 (48.6) 13 (37.1)
Child with CKD 40 0 0 1 (2.5) 10 (25) 29 (72.5) 35 0 0 3 (8.6) 14 (40) 18 (51.4)
Other children 30 0 1 (3.3) 0 11 (36.7) 18 (60) 25 0 0 2 (8) 13 (52) 10 (40)
Friends 40 3 (7.5) 3 (7.5) 10 (25) 12 (30) 12 (30) 35 0 0 8 (22.9) 18 (51.4) 9 (25.7)
Nurses 40 1 (2.5) 0 0 15 (37.5) 24 (60) 25 1 (4) 0 1 (4) 13 (52) 10 (40)
Doctors 40 1 (2.5) 0 1 (2.5) 13 (32.5) 25 (62.5) 25 1 (4) 0 2 (8) 12 (48) 10 (40)
Social workersa 40a 3 (7.5) 0 1 (2.5) 8 (20) 11 (27.5) 25b 3 (12) 2 (8) 0 3 (12) 3 (12)
CKD chronic kidney disease
Data shown as a number (%)
a 17 mothers (42.5 %) did not deal with social workers; b 14 fathers (56 %) did not deal with social workers
Pediatr Nephrol (2013) 28:2157–2167 2163
Table 5 Paediatric Quality of Life Inventory (PedsQL) 4.0 generic core scales from child’s self-report (for ages 5–18; n= 31) and parent–proxy
report (main caregivers and second parents)
Characteristic APD children n =31 Main caregivers of APD children n=31 Second parents of APD children n=13
Physical functioning 62.5 (50.0–75.0) a,b 56.24 (40.63–62.5) 53.13 (39.84–65.63)
Emotional functioning 70.0 (56.25–73.75) a,b 55.0 (40.0–70.0) 55.0 (50.0–71.25)
Social functioning 70.0 (50.0–90.0) a 55.0 (40.0–70.0) 65.0 (53.75–81.25)
School functioning 62.5 (50.0–75.0) 55.0 (35.0–65.0) 60.0 (47.5–70.0)
Overall HRQoL 64.13 (51.09–75.0) a,b 54.35 (38.87–64.13) 54.35 (48.91–63.32)
Data are presented as median and quartiles (first–third quartile)
APD automated peritoneal dialysis
a APD children vs. main caregivers, p< 0.05
b APD children vs. second parents, p< 0.05
3.25–4.0) (p= 0.03). Parents living in small towns also per-
ceived less available emotional support and sought it to a
lesser extent than did others; however, differences were not
statistically significant. There was no correlation between
BSSS, CBS, and GHQ-12 results and duration of CKD,
remaining under the care of a nephrology specialist and the
duration of renal replacement therapy, or distance between
place of residence and a nephrology center. The method of
teaching a child (general; home school) had no effect on
parents’ test results. Parents who helped their children with their
studying differed significantly from parents who did not help
their children in terms of currently received information support
(2.9, 2.4–3.2 vs 3.4, 3.0–3.6; p=0.004) and instrumental support
(3.2, 2.4–3.8 vs 4.0, 3.2–4.0; p=0.02), which they rated lower.
A statistically significant negative correlation was found
between PedsQL (total score) and CBS (total burden index)
(r= −0.51, p= 0.001) and GHQ-12 (r= −0.55, p = 0.0002); a
positive correlation was found between PedsQL (total score)
and certain BSSS subscales: need for support (r = 0.31, p
=0.05), support seeking (r= 0.36, p =0.02), perceived avail-
able emotional support (r= 0.65, p= 0.001), and instrumental
support (r = 0.32, p= 0.04). Also, the following correlations
were observed: a positive correlation between CBS (total
burden index) and GHQ-12 (r= 0.73, p= 0.001) and negative
Table 6 General …
T
The Effects of Kidney-Disease-Related Loss on Long-Term
Dialysis Patients’ Depression and Quality of Life: Positive
Affect as a Mediator
Ramony Chan,*† Robert Brooks,‡ Jonathan Erlich,§ Josephine Chow,† and Michael Suranyi†
*Consultation Liaison Psychiatry, †Renal Unit, and ‡Centre for Population Mental Health Research, Liverpool Hospital,
and §Department of Nephrology, Prince of Wales Hospital, Sydney, New South Wales, Australia
Background and objectives: In kidney disease, the concept of loss is widely discussed but minimally researched. It appears
that dialysis patients who grieve a range of losses suffer increased depression and reduced quality of life (QoL). Limited
research is partly due to the lack of a relevant loss measure. The study presented here developed a measure and tested the
criterion validity of loss in relation to depression and QoL.
Design, setting, participants, & measurements: In a cross-sectional observational study, 151 long-term dialysis patients were
interviewed using standardized psychometric measures and the Kidney Disease Loss Scale (KDLS), developed for the study.
Factor, path and multigroup analyses were conducted.
Results: The factor structure and reliability of KDLS were supported. The path analyses supported the criterion validity of
loss. It was a stronger contributor to depression than other clinical variables. Its effect on QoL was fully mediated by depression
and positive affect (coping). The magnitude of the paths from loss to QoL through depression and positive affect was larger in
home-based dialysis patients than in hospital-based patients.
Conclusions: KDLS is a promising measure of loss. Patient-defined losses may contribute to the high level of depression and
in turn a reduction in patients’ coping and QoL. These findings suggest several points of intervention to improve long-term
dialysis patients’ QoL.
Clin J Am Soc Nephrol 4: 160 –167, 2009. doi: 10.2215/CJN.01520308
he concept of Kidney-Disease-Related Loss (KDRL) in
ESRD has been clinically and theoretically significant
for decades (1– 4). ESRD patients experience multiple
losses, both tangible and symbolic; for example, loss of physical
strengths, freedom, employment, and social life, resulting in
grief throughout the course of ESRD and dialysis (1,2,4). Re-
solving loss successfully is identified as one of the adaptational
factors in ESRD (3). Although widely discussed, there exists no
clear definition or measure of KDRL.
Loss, traditionally discussed in the context of death, has
recently been broadened to comprise loss of significant ele-
ments in a person’s life due to chronic illness (5,6). In chronic-
illness-caused losses, individual grief responses, rather than
actual losses, are of conceptual importance (6). These grief
responses, which can persist for many years and cause signif-
icant dysfunctions, are shown to be empirically and conceptu-
ally different from depression and anxiety in several studies (7–
10). The grief symptomatology is characterized by cognitive
preoccupation or rumination, yearning, disbelief, stunned re-
sponses, and nonacceptance of losses (7,9,11), which could be
summarized as cognitive and affective grief responses (6). Thus,
the study presented here defines KDRL as the cognitive and
affective grief responses after tangible and symbolic losses due
to kidney disease and its treatments. This definition will guide
the development of a measure for KDRL.
KDRL has traditionally been seen as one of the causes of
depression in ESRD patients. In the psychodynamic perspec-
tive, depression may be an extension of patients’ grief re-
sponses (1) or KDRL may increase patients’ vulnerability to
developing depression (4). In the cognitive-behavioral perspec-
tive, patients’ cognitive rumination over their losses may lead to
depression, as negative rumination has been found to be
associated with depression (12,13).
There exists a strong inverse relationship between depression
and quality of life (QoL) in ESRD patients (14,15). If KDRL is a
significant cause of depression, it may have a mediated effect on
QoL through depression or KDRL may also independently affect
both depression and QoL. Although the literature sug- gests a
direct relationship between depression and QoL, posi- tive affect
as a way of coping (16,17) may mediate the effect of depression
and loss (18). Positive affect may have adaptive
values in dealing with chronic stress (16,17) and thus moderate
Received March 31, 2008. Accepted July 23, 2008.
Published online ahead of print. Publication date available at www.cjasn.org.
Correspondence: Ramony Chan, Consultation Liaison Psychiatry, Liverpool Hos-
pital, Locked Bag 7103, Liverpool BC, New South Wales 1871, Australia. Phone: 61-
2-9616-4680; Fax: 61-2-9616-4691; E-mail: [email protected]
the effect of depression and KDRL on QoL.
The clinical validity of KDRL can be understood not only by
measuring it, but also by examining its relations to clinical
variables, including medical comorbidity, length of time on
dialysis, and level of hemoglobin and its effects on hospital-
Copyright © 2009 by the American Society of Nephrology ISSN: 1555-9041/401–0160
http://www.cjasn.org/
mailto:[email protected]
Clin J Am Soc Nephrol 4: 160 –167, 2009 Role of Loss in Kidney Disease 161
and home-based dialysis patients. It is hypothesized that pa-
tients’ KDRL will covary with these clinical variables influenc-
ing QoL through depression and positive affect (15,19 –23).
Moreover, the clinical observation suggests that hospital-based
patients may experience more losses and become accustomed to
their effects, whereas home-based patients may regain or min-
imize some losses through the advantages of home treatments.
Thus, it is assumed that each additional loss for home-based
patients will have a greater effect on their well being and QoL, and
thus the clinical validity of the KDRL can be demonstrated.
The aim of this research is to show the criterion-related
validity of the KDRL construct by developing a measure for
KDRL, to examine its relationship with relevant psychologic
and clinical variables, and its effect on home-based dialysis
patients. It is hypothesized that (1) the proposed scale of KDRL
will consist of cognitive and affective grief responses and that
(2a) loss will lead to depression, (2b) covary with other clinical
variables to influence QoL through depression and positive
affect, and (2c) influence the home-based patients more.
Materials and Methods
Participants
Participants were recruited from two major university teaching hos-
pitals in Sydney South West Area Health Service (SSWAHS) and South
Eastern Sydney & Illawarra Area Health Service (SESIAHS) Sydney,
Australia. The inclusion criteria were a diagnosis of ESRD, receiving
dialysis treatment for approximately 2 yr or more and aged 18 or above.
The main exclusion criterion was incapacity to complete questionnaires
and/or the semistructured interview with reasonable assistance. Of 209
eligible patients, 31 (14.8%) refused, 7 (3.4%) withdrew during the
interview as being too sick to continue, 16 (7.7%) did not return the
questionnaires, and 4 (1.9%) did not complete the data collection be-
cause of death, transplant, acute medical problems, or cognitive im-
pairment. Thus, 151 (72.2%) patients participated in the interview and
returned the questionnaires. The sample consisted of 90 (60%) men and
61 women (40%) with the mean age 58 ± 14.28 (SD) yr, the mean
duration of dialysis was 67.97 ± 42.84 (SD) mo (range 22 to 248 mo).
Approximately half (n 68, 45%) of the participants were doing home-
based dialysis, including home hemodialysis (n 26, 17%) and peritoneal
dialysis (n 42, 28%), and the others (n 83, 55%) were on hospital-based
dialysis including satellite (n 56, 37%) and in-center hemodialysis (n 27,
18%).
Procedures
This study was approved by the SSWAHS and SESIAHS Ethics
Committees. After being informed of the study details and having
signed a consent form, participants completed the semistructured in-
terview and returned completed questionnaires by mail. One reminder
letter and spare questionnaire were sent to those who did not return the
questionnaires. Two interviewers were trained in the application of
measures before the initiation of the study to ensure the quality of the
data collection.
Measures
Seven variables were examined in the study: QoL, depression, KDRL,
positive affect (a key component of coping), medical comorbidity, length
of time on dialysis, and hemoglobin. In addition to developing a scale
to measure KDRL, standardized measures were used in the study—the
Schedule for Evaluation of Individual Quality of Life—
Direct Weighting (SEIQoL-DW) (24), the Depression Scale of Depres-
sion Anxiety Stress Scale 21 (DASS21) (25), the Positive Affect Scale
(PAS) (18), and the Comorbidity Index (CMI) (26,27). Additional ques-
tions were included to collect participants’ demographic and dialysis
related information including length of time on dialysis (the total
number of months). Hemoglobin level was an average over 3 mo,
including the month of the research interview.
The Kidney Disease Loss Scale
The measurement context in which an individual considers their
losses will in part determine the validity of the measurement. The con-
text can be determined from individual-defined losses or from a stan-
dard set of losses. The type and importance of losses varies widely
between patients and thus a predefined set of losses may only be
partially relevant to any individual’s experience (6,24). The Kidney
Disease Loss Scale (KDLS) was constructed to first elicit the five most
important individual KDRL and second to obtain cognitive and affec-
tive grief responses. A second-order factor structure of KDLS was
hypothesized with four statements measuring cognitive rumination and
four measuring the affective response to loss.
The SEIQoL-DW
The SEIQoL-DW is a patient-centered semistructured interview to
measure individual QoL (24). It was chosen because of known limita-
tions in multidimensional measures of QoL (28) and its ability to
produce both qualitative and quantitative data. Of particular impor-
tance for renal patients are that preselected life domains may not be
relevant, and equal weighting of life domains is inconsistent with
patients’ own values (29,30).
In the SEIQoL-DW, the five most important areas of a respondent’s
life are elicited, then the level of satisfaction and relative importance of
each area is determined. Its global index score, ranging from 0 to 100, is
the sum of a product of the ratings and weightings of each nominated
area. Its reliability, validity, and utility in the medical and ESRD pop-
ulations are excellent (24,30 –33).
The DASS21
The DASS21 is a 21-item scale, comprising of three subscales: depres-
sion, anxiety, and stress (seven items each), a total score for each
subscale ranging from 0 to 21. Only scores on the depression subscale
were used in the analyses. The DASS21 focuses on the cognitive and
affective aspects of depression, limiting the methods bias of using a
measure that contains somatic elements common to depression and
kidney disease (2,34,35). Additionally, it was developed in the Austra-
lian population (the site of this study); it has strong psychometric
properties in both general and clinical populations (25,36,37); it is
relatively short, reducing administrative burden on patients; and dif-
ferentiates depression, anxiety, and stress.
PAS
The PAS is a four-item scale on a Likert scale ranging from 0 (not at
all) to 10 (very much), with a total score ranging from 0 to 40 to measure
individual positive feelings. Its reliability and discriminant and conver-
gent validities have been well established (18).
CMI
The CMI was compiled on the basis of Friedman’s Index (26) and
Charlson’s Index (27). It is in a checklist format, with scores ranging
from 0 to 15, higher scores indicating more comorbid conditions.
162 Clinical Journal of the American Society of Nephrology Clin J Am Soc Nephrol 4: 160 –167, 2009
Data Analyses
Analyses were performed with SPSS 15 (38) and LISREL 8.72 (39).
Missing data were rare and nonsystematic and thus replaced using EM
(expectation-maximization) method (38,40). The first set of analyses
examined and validated the factor structure of the KDLS using confir-
matory factor analysis (CFA) and exploratory factor analysis (EFA).
Standard techniques of correlation, ANOVA, and t test were used with
a critical value of alpha set to 0.05. The final set of analyses used
structural equation modeling (SEM) to test, develop, and examine
alternative models. Multigroup analyses were used to compare hospital
and home dialysis.
The two-step approach was used with SEM (41). Composite scores of
the observed variables, using the unit-weighted addition method, were
calculated and error variances fixed in the measurement model (42,43)
before the structural model was tested. Because the distributions of the
observed variables were skewed, SEM was undertaken using “asymp-
tomatic distribution free covariance” matrices using the robust maxi-
mum likelihood and the Satorra-Bentler statistic for parameter estima-
tion (44 – 46). Several goodness-of-fit (GFI) indices were chosen to
evaluate the overall model fit (40): Satorra-Bentler x2 test (P > 0.05, in
SEM nonsignificant x2 indicates a good model fit), the GFI (>0.90),
adjusted GFI (AGFI) (>0.90), the root mean square residual (RMR; close
to 0), the root mean square error of approximation (RMSEA; <0.05, 90%
confidence interval <0.08), and the comparative fit index (CFI; >0.90).
Results
Development of KDLS
The hypothesized factor structure of KDLS was not sup-
ported using CFA [x2 73.44, degrees of freedom (df) 19, P 0.00,
RMSEA 0.09, GFI 0.89, AGFI 0.80, CFI 0.99,
RMR 0.05; LISREL 8.72 39]. Re-examining the data, EFA using
SPSS (38) indicated two factors with 72.24% of the total variance
explained. There were two items loading onto both factors and
therefore excluded (42). The first factor consisted of four items
and resembled cognitive responses and the second factor
consisted of two items reflecting affective responses. The second
factor was retained for its theoretical importance and the items’
correlation was greater than 0.7 (47). The two factors were
strongly correlated (r 0.71, P < 0.01), suggesting the previously
hypothesized second-order factor. The new factor structure and
possible second-order factor model were exam- ined using CFA
(x2 12.63, df 8, P 0.128, RMSEA 0.00, GFI 0.97, AGFI 0.93,
CFI 1.00, RMR 0.03) (LISREL 8.72 39). The
first-order factors measure cognitive and affective responses
and a second-order factor reflects an overall sense of loss re-
garding self-defined KDRLs. Therefore, the KDLS comprises an
overall loss scale by summing the six items (48) and two sub-
scales (see Table 1). High scores are indicative of greater sense
of loss, with more rumination and stronger affect. The internal
consistence of KDLS was good (a 0.88 for both the cognitive and
affective subscales).
The convergent and discriminant validity of KDLS were
supported by its significant positive correlation with depres-
sion (r 0.60, P < 0.01), and negative correlation with QoL (r
-0.20, P < 0.05) and positive affect (r -0.36, P < 0.01). It was
unrelated to clinical variables (hemoglobin r 0.07, comorbid-
ity r 0.04, length of time since dialysis r -0.15). Construct
validity was examined by conducting a two-factor EFA of the
six KDLS and the seven DASS21 depression items. The depres-
sion items loaded onto one factor and KDRL items loaded onto
another without cross-loading items.
Patients’ nominated losses on KDLS were codified by two
independent coders by iteratively examining the data. The
intercoder agreement was 95% and the differences in the re-
maining 5% were resolved by consensus. In total, 109 of 151
respondents nominated 431 losses. Of the 23 types of losses
identified, the seven most common were travel (18.56% of the
total nominated losses), leisure activities (12.06%), physical
functioning (10.90%), employment/work (9.74%), family/per-
sonal relationships (6.50%), freedom (perception of being free
from constraints; 4.87%) and social life (4.87%). The mean score
difference on KDLS between those who did not nominate losses
(x- 5.41) and those who did (x- 5.84) was nonsignificant (t 0.49,
df 149, P > 0.05).
Univariate Analyses
There was no gender differences in the variables used in the
study. An examination of differences between the two hospitals
identified a significant difference in hemoglobin levels (SS-
WSAH x- 123.84 (13.88), SESIAHS x- 117.13 (14.05), P <
0.01); there were no differences on other variables. There were
no treatment modality (in-center hemodialysis, home hemodi-
alysis, peritoneal dialysis, satellite hemodialysis) differences on
any variable.
Path Analyses
Model Testing and Modification. The structural relation-
ships between length of time on dialysis, hemoglobin, comor-
bidity, loss, depression, positive affect, and individual QoL
were examined using SEM. The hypothesized path model was
not supported (x2 16.57, df 8, P 0.04, RMSEA 0.09; for all
fit statistics see Table 2). Therefore, the model modification
process was conducted to improve the model fit by examining
the t-values of path coefficients, standardized residual values,
and modification indexes. The path from hemoglobin to de-
pression was insignificant and thus deleted, and an additional
path from comorbidity to positive affect added (x2 7.91, df 13,
P 0.85, RMSEA 0.00; see Table 2 and Figure 1), indi- cating a
plausible model for the observed data.
As shown in Table 3, each variable explained a small pro-
portion of variance in QoL with positive affect (9.6%) and
hemoglobin (4.8%) having the highest direct effect. The effects
on positive affect from comorbidity and length of time since
dialysis were moderate whereas depression explained the larg-
est proportion (29.2%) of variance in positive affect. Loss ex-
plained 38.4% of variances in depression, larger than comor-
bidity (2.3%) and length of time since dialysis (5.3%), and only
had a small effect on QoL fully mediated by depression and
positive affect.
Alternative Models
In covariance structure modeling, several equivalent mod- els
may exist (40). Two theoretically based alternative mod-
Clin J Am Soc Nephrol 4: 160 –167, 2009 Role of Loss in Kidney Disease 163
Table 1. The final version of the Kidney Disease Loss Scale (KDLS)a
When you consider life as it is now with kidney disease and dialysis treatments, it is clearly different from what
your life used to be or would have been. You might find yourself having lost many things. Please consider
LOSSES: things that you used to do before kidney disease/dialysis and now you cannot do anymore or things
that you would have been doing if you did not have kidney disease/dialysis. Please list below the five most
important things you have lost because of the kidney disease/dialysis.
1:
2:
3:
4:
5:
In regard to the five losses described above, please read each of the following statements carefully and circle a
number 0, 1, 2 or 3 that indicates how much the statement applied to you
The rating scale is as follows:
0 Did not apply to me at all
1 Applied to me to some degree, or some of the time
2 Applied to me to a considerable degree, or a good part of time 3
Applied to me very much, or most of the time
1. I think about these losses so much that it is hard for me to do
the everyday things I normally do 0 1 2 3
2. Memories of the losses upset me 0 1 2 3
3. I am preoccupied with thoughts of the losses 0 1 2 3
4. I feel myself longing for regaining what I have lost 0 1 2 3
5. I feel disbelief over what happened 0 1 2 3
6. I feel stunned or dazed over what happened 0 1 2 3
aThe first part of the KDLS that requires respondents to nominate the five most important losses must be retained when the
KDLS is used, because it sets the context for rating the six items.
els were also tested. Alternative model 1 was to examine if
depression has a direct effect on QoL, and alternative model 2
was to investigate the ordinal relations between KDRL and
depression. The x2 difference statistics showed that alterna-
tive model 1 was not a better model (x2D 1.85, dfD 1,
nonsignificant, P < 0.05; also see Table 2). Alternative model 2
was rejected by the fit statistics (Table 2); depression does not
precede KDRL.
Table 2. The goodness-of-fit statistics of the hypothesized, modified, and alternative modelsa
Path Models Goodness-of-Fit Statistics
Hypothesized path model x2 df P GFI AGFI RMR RMSEA 90%CI CFI
16.57 8 0.04 0.97 0.89 16.25 0.09 0.02 to 0.14 0.95
Modified path model x2 df P GFI AGFI RMR RMSEA 90%CI CFI
7.91 13 0.85 0.99 0.97 15.81 0.00 0.00 to 0.05 1.00
Alternative model 1b x2 df P GFI AGFI RMR RMSEA 90%CI CFI
6.06 12 0.91 0.99 0.98 17.42 0.00 0.00 to 0.03 1.00
Alternative model 2c x2 df P GFI AGFI RMR RMSEA 90%CI CFI
41.20 13 0.00 0.93 0.84 13.33 0.12 0.08 to 0.16 0.84
ax2, Satorra-Bentler scaled chi-square; df, degrees of freedom; GFI, goodness-of-fit index; AGFI, adjusted GFI; RMR, root
mean square residual; RMSEA, root mean square error of approximation; NNFI, non-normed fit index; CFI, comparative fit
index.
bAdditional path from depression to quality of life was added in the model.
cKidney-disease-related loss precedes depression, given all other parameters being constant.
164 Clinical Journal of the American Society of Nephrology Clin J Am Soc Nephrol 4: 160 –167, 2009
Figure 1. Path diagram of the final modified model of KDRL. QoL, quality of life; PA, positive affect; KDRL, kidney-disease-related
loss; CM, comorbidity; LT, length of time since dialysis (months); Hb, hemoglobin level. Figures in gray are standardized
coefficients. Figures in brackets are estimates.
KDRL in Relation to the Treatment Location Effect
To further demonstrate the criterion validity of KDRL, a
multigroup analysis on the hospital- and home-based dialy- sis
patients was conducted. The poor global fit statistics (x2
135.66, df 38, P 0.00, RMESA 0.19) suggested
differences between the two groups. A reasonable fit (x2 43.87,
df 34, P 0.12, RMSEA 0.06) of the re-specified model
suggested that the main difference was a greater strength of
the relations between KDRL, depression, positive affect, and
QoL in home-based dialysis patients, although
Table 3. Standardized direct, indirect, total effects of the variablesa
CMI Loss Hemoglobin Length of Time Since Dialysis Positive Affect Depression
Direct effects
QoLb -
Positive affect -0.23
Depression 0.16
Indirect effects
QoL
-0.10
-0.11
-
-0.04
-
-0.17
Positive affect -0.08 -0.34 - -0.12 - -
Depression - - - - - -
Total effects
QoL
-0.10
-0.11
0.22
-0.04
0.31
-0.17
Positive affect -0.31 -0.34 - -0.12 - -0.54
Depression 0.16 0.62 - 0.23 - -
aStandardized total effect is the sum of direct and indirect effects of one variable on another variable. Its value ranges from
0 to 1 with either negative or positive direction. The larger the value is, the stronger the effect is.
bQoL, quality of life.
-
-
0.22
-
-
-
0.31
-
-
-0.54
0.62 - 0.23 - -
Clin J Am Soc Nephrol 4: 160 –167, 2009 Role of Loss in Kidney Disease 165
mean score differences on these variables between the
groups were nonsignificant.
Discussion
The study presented here provides empirical support for
KDLS and the hypotheses that loss leads to depression, cova-
ries with length of time since dialysis to influence QoL through
depression and positive affect, and has greater effect on home-
based patients. Moreover, the moderate direct effect that he-
moglobin has on QoL is consistent with previous clinical trials
showing erythropoietin treatment enhances ESRD patients’
QoL (49).
The concept of KDRL is operationalized by KDLS, which has
encouraging psychometric properties. Consistent with previ-
ous research, depressive and loss symptoms loaded onto sep-
arate factors, and the path analyses demonstrated that KDRL
precedes depression (7–10). Thus the KDRL is empirically dis-
tinct from depression. The cognitive rumination, yearning, dis-
belief, and stunned responses remain the key symptomatology
that contributes to depression.
KDRL as a strong contributor to depression is consistent with
the previous theories that loss is a significant cause of depres-
sion. Although the findings presented here may not support
depression as being an extension of KDRL, whether depression
is due to increased vulnerability or cognitive rumination over
negative contents of loss remains equivocal. Perhaps, more
cognitive rumination items contributing to the total score of
KDLS may suggest that cognitive rumination is the underlying
mechanism between KDRL and depression. Nevertheless, the
findings that travel, leisure activities, and physical functioning
are the most nominated types of losses may not be surprising
clinically, because many dialysis patients commonly describe
their dialysis experiences as being restrictive. Therefore, these
results may suggest that to improve patients’ depression and
QoL, psychosocial interventions could target loss; for example,
helping patients to regain losses by helping them to travel or
perform activities more, or to process their related thoughts and
feelings by reducing their cognitive ruminations. Encour-
agingly, these findings have already changed the educational
practice of one of the renal units where the study was con-
ducted.
Another interesting finding of the study is that the effect of
both KDRL and clinical variables on QoL is mediated by de-
pression and positive affect. This shows that disease-specific
variables may influence QoL indirectly through psychologic
states (50). However, the type of psychologic states has not been
explicitly specified, but rather implicitly assumed to be
depression in the ESRD literature. The findings presented here
suggest that both positive and negative psychologic states could
act as mediators. Positive affect may be a distinct factor and has
adaptive values buffering the effect of loss and depres- sion on
QoL (17,18).
The criterion validity of the KDRL construct is also illustrated
by the multigroup analyses showing that a stronger magnitude
of the relations between KDRL and other psychologic variables
exists for home-dialysis patients. For a small increase in their
sense of loss, home-based patients experience more depression
and greater decline in positive affect and QoL than do the
hospital-based. This may mean that psychosocial interventions
for home-based dialysis patients, especially on the KDLS and
depression, could result in greater improvement in their QoL
and potentially delay the need for hospital-based treatment.
The study presented here has several limitations. The KDLS is
a newly developed scale and awaits further research to
crossvalidate its validity and reliability. Future research may
also focus on item generation for the affective subscale of KDLS
to improve its construct validity. Because the main purpose of
the path analyses results was to examine the construct validity
of the KDLS, the substantive meaning of the model requires
replication in different samples. The sample size for the multi-
group analyses is considered small in SEM, and although con-
sistent with preliminary expectations, the interpretation of these
results should be cautious.
Overall, the study presented here demonstrated the construct
and criterion validity of KDRL and the promising psychometric
properties of KDLS. KDRL may lead to depression and through
it reduces QoL. The effect of depression is mediated by the
coping mechanism of positive affect. The development of any
new scale requires multiple studies to fully understand its
properties. Studies in different populations (e.g., pre- and early-
dialysis patients) will also add to the construct validity.
Acknowledgments
The results of this paper were presented at the American Society of
Nephrology 40th Annual Scientific Conference, San Francisco, Califor-
nia, 2007 and the 43rd Annual Scientific Meeting of the Australian and
New Zealand Society of Nephrology, Gold Coast, Australia, 2007. The
abstract of this paper has been published in Nephrology (Chan, R, Brooks,
R, Erlich, J, Chow, J, Suranyi, M: The role of kidney disease related loss
in dialysis patients’ quality of life: depression and positive affect as
mediating …
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aragraphs (meaning 25 sentences or more). Your assignment may be more than 5 paragraphs but not less.
INSTRUCTIONS:
To access the FNU Online Library for journals and articles you can go the FNU library link here:
https://www.fnu.edu/library/
In order to
n that draws upon the theoretical reading to explain and contextualize the design choices. Be sure to directly quote or paraphrase the reading
ce to the vaccine. Your campaign must educate and inform the audience on the benefits but also create for safe and open dialogue. A key metric of your campaign will be the direct increase in numbers.
Key outcomes: The approach that you take must be clear
Mechanical Engineering
Organic chemistry
Geometry
nment
Topic
You will need to pick one topic for your project (5 pts)
Literature search
You will need to perform a literature search for your topic
Geophysics
you been involved with a company doing a redesign of business processes
Communication on Customer Relations. Discuss how two-way communication on social media channels impacts businesses both positively and negatively. Provide any personal examples from your experience
od pressure and hypertension via a community-wide intervention that targets the problem across the lifespan (i.e. includes all ages).
Develop a community-wide intervention to reduce elevated blood pressure and hypertension in the State of Alabama that in
in body of the report
Conclusions
References (8 References Minimum)
*** Words count = 2000 words.
*** In-Text Citations and References using Harvard style.
*** In Task section I’ve chose (Economic issues in overseas contracting)"
Electromagnetism
w or quality improvement; it was just all part of good nursing care. The goal for quality improvement is to monitor patient outcomes using statistics for comparison to standards of care for different diseases
e a 1 to 2 slide Microsoft PowerPoint presentation on the different models of case management. Include speaker notes... .....Describe three different models of case management.
visual representations of information. They can include numbers
SSAY
ame workbook for all 3 milestones. You do not need to download a new copy for Milestones 2 or 3. When you submit Milestone 3
pages):
Provide a description of an existing intervention in Canada
making the appropriate buying decisions in an ethical and professional manner.
Topic: Purchasing and Technology
You read about blockchain ledger technology. Now do some additional research out on the Internet and share your URL with the rest of the class
be aware of which features their competitors are opting to include so the product development teams can design similar or enhanced features to attract more of the market. The more unique
low (The Top Health Industry Trends to Watch in 2015) to assist you with this discussion.
https://youtu.be/fRym_jyuBc0
Next year the $2.8 trillion U.S. healthcare industry will finally begin to look and feel more like the rest of the business wo
evidence-based primary care curriculum. Throughout your nurse practitioner program
Vignette
Understanding Gender Fluidity
Providing Inclusive Quality Care
Affirming Clinical Encounters
Conclusion
References
Nurse Practitioner Knowledge
Mechanics
and word limit is unit as a guide only.
The assessment may be re-attempted on two further occasions (maximum three attempts in total). All assessments must be resubmitted 3 days within receiving your unsatisfactory grade. You must clearly indicate “Re-su
Trigonometry
Article writing
Other
5. June 29
After the components sending to the manufacturing house
1. In 1972 the Furman v. Georgia case resulted in a decision that would put action into motion. Furman was originally sentenced to death because of a murder he committed in Georgia but the court debated whether or not this was a violation of his 8th amend
One of the first conflicts that would need to be investigated would be whether the human service professional followed the responsibility to client ethical standard. While developing a relationship with client it is important to clarify that if danger or
Ethical behavior is a critical topic in the workplace because the impact of it can make or break a business
No matter which type of health care organization
With a direct sale
During the pandemic
Computers are being used to monitor the spread of outbreaks in different areas of the world and with this record
3. Furman v. Georgia is a U.S Supreme Court case that resolves around the Eighth Amendments ban on cruel and unsual punishment in death penalty cases. The Furman v. Georgia case was based on Furman being convicted of murder in Georgia. Furman was caught i
One major ethical conflict that may arise in my investigation is the Responsibility to Client in both Standard 3 and Standard 4 of the Ethical Standards for Human Service Professionals (2015). Making sure we do not disclose information without consent ev
4. Identify two examples of real world problems that you have observed in your personal
Summary & Evaluation: Reference & 188. Academic Search Ultimate
Ethics
We can mention at least one example of how the violation of ethical standards can be prevented. Many organizations promote ethical self-regulation by creating moral codes to help direct their business activities
*DDB is used for the first three years
For example
The inbound logistics for William Instrument refer to purchase components from various electronic firms. During the purchase process William need to consider the quality and price of the components. In this case
4. A U.S. Supreme Court case known as Furman v. Georgia (1972) is a landmark case that involved Eighth Amendment’s ban of unusual and cruel punishment in death penalty cases (Furman v. Georgia (1972)
With covid coming into place
In my opinion
with
Not necessarily all home buyers are the same! When you choose to work with we buy ugly houses Baltimore & nationwide USA
The ability to view ourselves from an unbiased perspective allows us to critically assess our personal strengths and weaknesses. This is an important step in the process of finding the right resources for our personal learning style. Ego and pride can be
· By Day 1 of this week
While you must form your answers to the questions below from our assigned reading material
CliftonLarsonAllen LLP (2013)
5 The family dynamic is awkward at first since the most outgoing and straight forward person in the family in Linda
Urien
The most important benefit of my statistical analysis would be the accuracy with which I interpret the data. The greatest obstacle
From a similar but larger point of view
4 In order to get the entire family to come back for another session I would suggest coming in on a day the restaurant is not open
When seeking to identify a patient’s health condition
After viewing the you tube videos on prayer
Your paper must be at least two pages in length (not counting the title and reference pages)
The word assimilate is negative to me. I believe everyone should learn about a country that they are going to live in. It doesnt mean that they have to believe that everything in America is better than where they came from. It means that they care enough
Data collection
Single Subject Chris is a social worker in a geriatric case management program located in a midsize Northeastern town. She has an MSW and is part of a team of case managers that likes to continuously improve on its practice. The team is currently using an
I would start off with Linda on repeating her options for the child and going over what she is feeling with each option. I would want to find out what she is afraid of. I would avoid asking her any “why” questions because I want her to be in the here an
Summarize the advantages and disadvantages of using an Internet site as means of collecting data for psychological research (Comp 2.1) 25.0\% Summarization of the advantages and disadvantages of using an Internet site as means of collecting data for psych
Identify the type of research used in a chosen study
Compose a 1
Optics
effect relationship becomes more difficult—as the researcher cannot enact total control of another person even in an experimental environment. Social workers serve clients in highly complex real-world environments. Clients often implement recommended inte
I think knowing more about you will allow you to be able to choose the right resources
Be 4 pages in length
soft MB-920 dumps review and documentation and high-quality listing pdf MB-920 braindumps also recommended and approved by Microsoft experts. The practical test
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One thing you will need to do in college is learn how to find and use references. References support your ideas. College-level work must be supported by research. You are expected to do that for this paper. You will research
Elaborate on any potential confounds or ethical concerns while participating in the psychological study 20.0\% Elaboration on any potential confounds or ethical concerns while participating in the psychological study is missing. Elaboration on any potenti
3 The first thing I would do in the family’s first session is develop a genogram of the family to get an idea of all the individuals who play a major role in Linda’s life. After establishing where each member is in relation to the family
A Health in All Policies approach
Note: The requirements outlined below correspond to the grading criteria in the scoring guide. At a minimum
Chen
Read Connecting Communities and Complexity: A Case Study in Creating the Conditions for Transformational Change
Read Reflections on Cultural Humility
Read A Basic Guide to ABCD Community Organizing
Use the bolded black section and sub-section titles below to organize your paper. For each section
Losinski forwarded the article on a priority basis to Mary Scott
Losinksi wanted details on use of the ED at CGH. He asked the administrative resident