Although there have been several studies about the quality of life in patients on hemodialysis globally, to the best of our knowledge, this is the first-ever study on the quality of life of kidney failure patients on hemodialysis in Cameroon. The principal finding of this study was that approximately three-quarters of the proportion of patients with kidney failure on dialysis had lower QOL. These findings were consistent with studies in Ethiopia, Kenya, Rwanda, and the US [17–20]. However, our QOL is lower than that reported by Cohen et al. in the US and Shahrin et al. in Malaysia, who reported slightly higher QOL[20,21]. This could be explained by the differences in dialysis delivery in these settings, as the 3 times weekly frequency of dialysis performed in these other studies could impact QOL positively compared to the 2 times weekly dialysis frequency performed in our study. Many studies have shown the relationship between higher frequency dialysis and better HRQOL in kidney failure patients [22]. Lower scores may indicate poor prognosis of the patients and compromised quality of clinical care. The findings of this study underscore that there is a need to assess the patients' QOL during the follow-up, and appropriate measures must be taken to reassure the patients.
The burden of kidney disease was the subscale where participants obtained the lowest mean score, indicating how much kidney failure interferes with daily lifetime taking, frustrating and making the respondent feel like a burden. The good scores in the symptom/problem subscales were due to the subjects' familiarity over time with pain, uremic symptoms, and others while having their way to overcome these. This finding corresponds to those reported by authors in studies performed in Africa and Europe [7,9,13,23]. PCS scores were lower than MCS scores, consistent with studies performed in Chile and Mangalore [22,24], where participants had higher MCS scores, indicating that despite the worsening of the physical health status, the mental health of dialysis patients is relatively preserved. This may reflect the ability of kidney failure patients to adapt psychologically to their situation over time[25]. Moreover, these results are consistent with those of studies conducted in the Netherlands and Oman [26].
HRQOL was found to be associated with older age, and increasing age has been shown to negatively affect HRQOL [17,21,27] due to short life expectancy and more comorbid conditions, such as depression and cognitive disorders [28]. Although multiple studies have shown a significant correlation between employment status and level of income, this study failed to identify any statistically significant correlation between these factors, possibly due to differences in the homogeneity of the population, but our findings corroborate Kamau et al. in Kenya, who found no associating factors[18]
Young adult patients on HD are at an important stage of development when kidney failure may adversely influence progress in education and employment. Of the proportion of participants who were students, the majority (67.1%) dropped out following dialysis initiation. It has been shown that people with chronic health conditions are at an increased risk of school dropout in the general population [29]. Additionally, there are reasons why people on dialysis may stop going to school, including financial obligations, fitting dialysis sessions with a school schedule, and the general conception of having no life while on dialysis [10]. Meanwhile, school continuation was mostly hindered by physical insufficiency (82.4%), leading to school absenteeism. This is consistent with studies performed by Murray et al. and Clave et al. in the US [30,31].
Only a small proportion of kidney failure patients are employed at the start of dialysis compared with the general population. However, people with chronic diseases such as kidney failure are heavily burdened not just by the disease but also by the treatment modalities, which are major contributors to reduced employment rates[32]. In this study, the ratio of unemployment was high (44%) in maintenance HD working-age patients, with the principal reason being physical insufficiency, consistent with studies in China and Japan [32,33]
We recorded that 9 (2.1%) had divorced while on dialysis, and statistics show that 75% of marriages afflicted with a chronic illness end in divorce[34]. Meanwhile, approximately one-third of those who married reported that dialysis had affected their relationship negatively with their spouses, as they felt like a burden to them. Studies have shown that chronic diseases impact the relationships of patients, especially as they are time consuming, and financial responsibilities and the length of time spent dealing with chronic diseases can often shift the balance of a relationship. More than two-thirds of those of marriageable ages reported that dialysis and their general health condition posed a limitation to them getting stable relations and finding suitors. Furthermore, half of our participants agreed that relatives and friends distanced themselves from them, saying their illness was mystical. This shows that some of these patients lack the necessary support from relatives.
Social participation was greatly hampered by dialysis inception in 267 (61.5%) of the population. This is probably because the incapacitation of chronic HD patients often results in social isolation and self-isolation from society. They are therefore faced with issues of social adaptation and resocialization, posing a change in the lifestyle of these patients causing them not to be able to keep up with previous regular activities, which was similar to studies conducted by Kerklaan et al. in 6 countries [35].
HRQOL was found to be associated with social reinsertion. Those with poor QOL were reinserted poorly into society in terms of social participation. This is because these patients are socially vulnerable and limited in what they can accomplish. Therefore, many are forced to readjust their lives to cope with their chronic disease, and this involves withdrawal from social activities, strict limitations on travel to avoid compromising dialysis sessions, and avoidance of ceremonies to adhere to their fluid and diet restrictions[32].
One of the major limitations of this study was that we did not evaluate the possible effects of biochemical parameters such as haemoglobin and phosphorus levels on the QOL of patients. As a strength, our study had a larger sample size compared to other studies performed in Sub-Saharan Africa, and the fact that it was conducted in the 4 most active haemodialysis units in 3 urban regions of Cameroon could help us generalize the results to reflect the national perspective. Second, this study has provided data on QOL and social reinsertion of HD patients in Cameroon, exposing factors associated with such low QOL.
STUDY LIMITATIONS
The major limitation of this study was that we did not evaluate the possible effects of biochemical parameters on the QOL of patients on HD. Additionally, the majority of the questionnaires were reported by the investigator; in these cases, reporting biases could have acted as a confounding factor in our data.