The Relationship between Symptom Management, Depression Status, and Spiritual Care Requirement in Hemodialysis Patients in Turkey: A Correlational Study

doi:10.21203/rs.3.rs-5331180/v1

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Research Article

The Relationship between Symptom Management, Depression Status, and Spiritual Care Requirement in Hemodialysis Patients in Turkey: A Correlational Study

https://doi.org/10.21203/rs.3.rs-5331180/v1

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This study aimed to investigate the relationship between depression status, spiritual care needs, and symptom management in patients on hemodialysis.

METHOD:. A previous study reported that spiritual health was one of the negative predictors of depression in hemodialysis patients (Upper: 0.90, Lower: 0.75, R2: 0.58) (24). based on the results of above study, the sample size was calculated using the G*Power software Version 3.1.9.7. Accordingly, it was found that the sample size should be at least 115 with a power of 0.80 and a margin of error of 0.05. The study sample included 119 individuals. The post hoc power of the study was 0.84.

RESULTS: Upon correlation analysis, there was a moderate positive correlation between dry weight and BDI and a weak negative correlation between DSI and SCNI. The difference was statistically significant (p < 0.005) (Table 5). There was no significant relationship between other scale scores

CONCLUSION: All HD patients had depressive traits. The spiritual care needs of these patients are much higher compared to average. The most important results of this study were that all HD patients had depressive symptoms, symptom burden was higher, and the need for spiritual care was higher.

depression

hemodialysis

Symptom Management

Spiritual Care

Approximately 70% of patients on renal replacement therapy undergo hemodialysis procedure (HD).(1) HD treatment is vital for the patients. Nevertheless, patients may have a number of symptoms during this treatment process and their symptom burden is considered high.(2) The most prevalent symptoms include dry mouth,(3) loss of appetite,(4) fatigue,(5) constipation,(6) and cough.(7) It was suggested that as the spiritual well-being of the individual increases, symptoms related to the disease decrease.(8, 9) Furthermore, it is well-established that patients’ symptoms may trigger signs of depression.(10) The severity of depression is varied in patients, who undergo HD. Yet, it was reported that typically more than a half of the patients would have depressive symptoms (11). Depression is triggered by a range of factors in this patient group.(12–15) However, the depressive state of these patients can be relieved by nursing interventions.(16)

Spiritual care has a positive effect on depression in HD patients.(17, 18) The greater the spirituality of the individual, the greater the ability to cope with problems.(18) Spiritual care as provided by nurses can make a great contribution to patients (19, 20). Previous studies reported the effectiveness of spiritual care in different patient groups, and it was recommended to evaluate the spiritual care needs of patients (21–23). This study aimed to investigate the relationship between depression status, spiritual care needs, and symptom management in patients on hemodialysis. Research questions:

What is the level of symptom management, depression, and spiritual care needs in patients on hemodialysis?

What are the most prevalent symptoms in patients on hemodialysis?

Is there a relationship between depression, spiritual care needs, and symptom management in patients on hemodialysis?

The present study was designed as descriptive and correlational research.

Population and sample

The study population consisted of patients on hemodialysis treatment in a university hospital and a private dialysis center.

Sample

The size of the study sample was calculated based on dependent variables. A previous study reported that spiritual health was one of the negative predictors of depression in hemodialysis patients (Upper: 0.90, Lower: 0.75, R²: 0.58) (24). based on the results of above study, the sample size was calculated using the G*Power software Version 3.1.9.7. Accordingly, it was found that the sample size should be at least 115 with a power of 0.80 and a margin of error of 0.05. The study sample included 119 individuals. The post hoc power of the study was 0.84.

Inclusion criteria

Individuals, who aged older than 18 years, started HD treatment at least 6 months ago, and had no communication barriers were included in the study, where 8 individuals, who were in the terminal period, continued cancer treatment, and had cognitive problems were excluded.

Data Collection Forms and Data Collection

"Socio Demographic Information Form", "Beck’s Depression Inventory", "Spiritual Care Needs Scale," and "Dialysis Symptom Index in Chronic Hemodialysis Patients" were used for data collection purposes.

Socio Demographic Information Form

The form was developed by the researchers based on the relevant literature.(25–27) The form included a total of 12 sociodemographic and disease-related items.

Beck’s Depression Inventory

Beck’s Depression Inventory (BDI) was developed by Beck et al. and its Turkish validity and reliability study was conducted by Hisli. BDI can be used to assess the severity of depression in both healthy and psychiatric populations. It was designed as a 21-item self-report inventory. The Beck’s Depression Inventory (BDI) assesses cognitive, behavioral, emotional, and somatic dimensions of depression. The assessment is based on the last 2 weeks, including the assessment day. The four-point Likert-type scale consists of twenty-one items. Each item assesses symptom severity on a scale of 0–3. BDI items are presented with four possible responses of ''(0) I do not feel sad, (1) I feel sad, (2) I am sad all the time and I can't snap out of it, (3) I am so sad or unhappy that I can't stand it". The total score ranges between 0–63. A BDI score of 0–9 points is associated with minimal depression, where 10–16 points with mild, 17–29 points with moderate, and 30–63 points with severe depression. The Cronbach's alpha coefficient of the Turkish scale was 0.74 (Hisli, 1989). The alpha value for this study was 0.83.

Spiritual Care Needs Scale

The Scale of Spiritual Care Needs (SCNI) was developed by Wu et al. (28), and its Turkish validity and reliability were studied by Günay İsmailoğlu et al. (2019). The scale was aimed to assess spiritual care needs regardless of the type of illness and religious beliefs. It was designed as a twenty-one-item scale. Patients are asked to rate the need for spiritual care for themselves on a 5-point Likert scale. The possible responses are 1="Not at all necessary", 2="Not necessary", 3="Does not matter", 4="Necessary", 5="Absolutely necessary". An increase in the mean total score of the scale is indicative of a higher need for spiritual care. There are two sub-domains in the scale; namely "meaning and hope" and "care and respect". The “meaning and hope” component includes expressions of spiritual well-being in relation to self, nature, and environmental factors; where the caring and respect component includes expressions in relation to relationships with others. "Meaning and hope" subdomain consists of the items 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 14; while the "Caring and respect" subdomain includes 13, 15, 16, 17, 18, 19, 20, and 21. For scoring the scale, the scores of each subdomain are summed. The minimum and maximum possible score from the scale is 21 and 105, respectively. The scale has no cut-off point, and an increase in the score is indicative of an increase in the patient's spiritual care needs. Cronbach's alpha coefficient of the Turkish scale was 0.94 (29). The alpha value for this study was 0.88.

Dialysis Symptom Index in Chronic Hemodialysis Patients

The Dialysis Symptom Index (DSI) was developed by Weisbord et al. with an aim to investigate the symptoms experienced by HD patients and their level of impact on the patient (2004).(30) The Turkish validity and reliability of the scale was studied by Önsöz and Usta Yeşilbalkan (2013). This scale inquiries the symptoms experienced by individuals in the last seven days. There are 30 items included in the five-point Likert-type scale. Scoring is based on the following responses: 1 = none, 2 = somewhat, 3 = sometimes, 4 = very little, 5 = very much. Individual scores are summed to obtain a total scale score. The total score ranges between 30–150, with higher scores are indicative of increased symptom burden. The scale does not have a cut-off point. The Cronbach's alpha coefficient of the Turkish scale was 0.83 (31). The alpha value for this study was 0.78.

Data Collection

Data were collected by face-to-face interview by the investigators in the HD unit, protective measures were taken for the risk of infection, patients were briefed, and their verbal and written consents were obtained. Data collection period was approximately 20 minutes.

Variables of the Study

Dependent variable: Depression score, symptom burden score, spiritual care need score was set as independent variables: Sociodemographic and disease-related characteristics.

Ethical Dimension of the Research

Relevant permissions were obtained from Necmettin Erbakan University Health Sciences Scientific Research Ethics Committee (2024/695) and hemodialysis unit. The STROBE checklist and the World Medical Association (WMA) Declaration of Helsinki were followed at all stages of the study.

Statistical Analysis

The Statistical Package for Social Sciences (SPSS) version 29.0 software was used for the purposes statistical analyses in the scope of the study. Mean and standard deviation were used for continuous variables and number and percentage were used for categorical variables. The hypothesis of normal distribution for continuous tested by an analysis of the Skewness and Kurtosis values, where a range of -1/+1 was considered normal, and the histogram and bell curve were also taken into consideration. BDI total score did not meet normal distribution hypothesis, while all other variables were normally distributed. Levene's test statistic was used to see the homogeneity of variances.

Independent samples t test and One-way ANOVA tests were used for data, which met normal distribution hypothesis. For one-way analysis of variance, Welch’s t-test (Robust test in one-way heteroscedastic ANOVA) statistic was used in cases where variances were not distributed homogeneously. Mann-Whitney U Test and Kruskal-Wallis H Test were used to analyze the data that were not normally distributed. Bonferroni and Tamhane's T² post hoc multiple comparison tests were used to understand the source of the difference between the groups. The Pearson and Sperman Correlation analysis were used to understand the relationship between continuous variables. It was considered that a correlation coefficient indicated a weak relationship between r = 0.1–0.3, a moderate relationship between r = 0.3–0.7, and a high relationship between r = 0.7-1.0. Reliability analyses for the total scale scores were conducted using Cronbach's α method. A p level of < 0.05 was considered statistically significant in all tests.

The results of the analysis of the study were presented in the order of the distribution of the scale scores used, reliability scores, comparison of scale scores with descriptive findings, and correlation analysis:

Table 1

Scale score distributions and reliability coefficients
	BDI	SCNI	DSI
Skewness	1,798	,164	,662
Std. Error of Skewness	,222	,222	,222
Kurtosis	4,665	-,763	-,622
Std. Error of Kurtosis	,440	,440	,440
Cronbach's alpha coefficient	0.83	0,88	0,78

The normality distributions and reliability coefficients of the scales used in this study are given in Table 1 (Table 1).

Table 2

Descriptive information of the participants and distribution of certain variables (n:119)
Variables	Mean	SD	Min		Max
Age	54,36	8,969	28		84
Dry weight	83,10	8,950	67		110
BMI	30,78	3,335	24		39
SCNI	73,19	7,675	59		89
DSI	27,84	6,124	20		54
	Median	Min- Max	Minimal		Moderate		Severe
			n	%	n	%	n	%
BDI	27,84	20–54	0	0	92	77,31	27	22,69
Sex	n		%
Male	49		41,2
Female	70		58,8
Duration of treatment
< 1 year	4		3,4
1–5 years	93		78,2
> 5 years	22		18,5
Educational status
Primary education	0		0
Secondary Education	83		69,7
University and above	36		30,3
Lived together with
Spouse and children	76		63,9
Mother-father-sibling	30		25,2
Other	13		10,9
Employment status
Paid employee	45		37,8
Retired	50		42,0
Unemployed	11		9,2
Housewife	13		10,9
Smoking status
Yes	60		50,4
No.	59		49,6
Vascular access route
AV fistula	103		86,6
CVC	16		13,4
Comorbid chronic diseases
Yes	89		74,8
No.	30		25,2
Physical disabilities
Yes	40		33,6
No.	79		66,4

Some of the mean values from the study participants were as follows: age: 54,36 ± 8,969, dry weight: 83,10 ± 8,950, BMI: 30,78 ± 3,335, total SCNI: 73,19 ± 7,675, total DSI: 27,84 ± 6,124, total BDI: 27,84 ± 20–54. Most of the participants were female (58.8%), had been on dialysis treatment for 1–5 years (78.2%), had completed secondary education (69.7%), lived with their spouse and children (63.9%), used AV fistula as vascular access route (86.6%), and had at least one chronic disease (74.8%). All participants had depressive tendencies. 77.3% of the participants had moderate and 22.69% had severe depressive signs (Table 2).

Table 3

Distribution by patients' symptoms (n:119)
	Yes		No.
Symptoms	n	%	n	%
Dry mouth	50	42,0	69	81,5
Loss of appetite	37	31,1	82	68,9
Fatigue	35	29,4	84	70,6
Constipation	28	23,5	91	76,5
Cough	26	21,8	93	78,2
Respiratory distress	25	21,0	94	79,0
Bone/joint pain	22	18,5	97	81,5
Vomiting	22	18,5	97	81,5
Need to move the legs	21	17,6	98	82,4
Skin dryness	21	17,6	98	82,4
Chest pain	18	15,1	101	84,9
Dizziness	17	14,3	102	85,7
Numbness in the feet	17	14,3	102	85,7
Decreased sexual interest	16	13,4	103	86,6
Cramps	14	11,8	105	88,2
Nausea	14	11,8	105	88,2
Feeling sad	14	11,8	105	88,2
Feeling anxious	14	11,8	105	88,2
Impaired sexual arousal	14	11,8	105	88,2
Edema in the legs	13	10,9	106	89,1
Inability to maintain sleep	13	10,9	106	89,1
Diarrhea	12	10,1	107	89,9
Trouble falling asleep	10	8,4	109	91,6
Feeling uncomfortable	10	8,4	109	91,6
Itching	10	8,4	109	91,6
Concentration problems	9	7,6	110	92,4
Headache	8	6,7	111	93,3
Muscle pain	8	6,7	111	93,3
Irritability	8	6,7	111	93,3
Anxiety	7	5,9	112	94,1

The number and percentage of symptoms reported by the participants due to hemodialysis are given in Table 3. The most prevalent symptoms included dry mouth (42.0%), loss of appetite (31.1%), fatigue (29.4%), constipation (23.5%), cough (21.8%), and respiratory distress (21.0%). The least prevalent symptoms included headache, muscle pain, irritability (6.7%), and anxiety (5.9%), details are given in the table (Table 3).

Table 4

Distribution of Scale Scores by independent variables (n:119)
	BDI			SCNI			DSI
Sex	Median (Min-Max)	1/3 Quartile	t/p	Mean	SD	t/p	Mean	SD	t/p
Male	29,55(21–54)	26,00/33,00	1276,000	74,57	7,168	0,979	81,37	9,667	1,939
Female	26,64(20–37)	24,00/28,00	0,017***	72,23	7,918	0,324*	74,81	9,218	0,166*
Duration of treatment
< 1 year	33,50(26–41)	26,00/41,00	2,202	78,00	12,702	0,924	75,50	4,041	3,478
1–5 years	33,35(26–41)	24,00/29,50	0,333****	72,86	7,738	0,400**	78,38	10,788	0,072**
> 5 years	26,00(21–33)	26,00/27,25		73,73	6,356		74,23	4,908
Educational status
Secondary Education	26,00(20–43)	24,00/28,00	864,00 0,001***	72,93	7,974	2,094	78,42	10,817	7,725
University and above	29,00(23–54)	26,00/34,00		73,81	7,005	0,151*	75,42	7,101	0,006*
Lived together with
Spouse and children	27,00(20–54^)b	23,00/29,00	12,344	71,00^c	6,184	10,252	78,96^a	10,675	3,470
Mother-father-sibling	25,00(24 − 3^)c	24,00/28,00	0,002****	76,50^b	8,685	0,001**	75,33^b	8,743	0,041**
^Othera	32,00(27–43^)a	27,00/41,00		78,38^a	8,422		74,08^c	5,530
Employment status
Paid employee	27,00(23–54^)b		8,964	74,67^b	6,862	7,503	74,36^d	6,779^d	3,644
Retired	26,00(21–43^)c	26,00/30,00	0,030****	73,08^c	7,499	0,001**	80,56^a	10,916^c	0,024**
Unemployed	25,00(24–36^)d	24,00/28,00		77,27^a	8,211		76,82^c	11,677^a
Housewife	28,00(20–32^)a	24,00/36,00		65,08^d	5,090		77,31^b	10,965^b
Smoking status
Yes	28,78(21–43)	24,50/32,00	1206,000	75,32	8,450	6,209	75,67	7,976	13,880
No.	26,88(20–54)	23,00/27,00	0,003***	71,03	6,148	0,014*	79,39	11,311	0,001*
Vascular access route
AV fistula	28,20(20–549	24,00/29,00	641,500	73,11	7,180	7,393	76,20	8,162	30,485
CVC	25,50(20–30)	23,00/28,75	0,154***	73,31	8,407	0,008*	79,39	11,811	0,001*
Comorbid chronic diseases
Yes	27,31(20–54)	23,00/29,00	908,000	73,27	8,313	9,084	76,96	10,427	4,443
No.	29,40(24–39)	25,00/32,50	0,009***	72,97	5,468	0,003*	79,17	8,112	0,037*
Physical disabilities
Yes	27,97(21–43)	22,00/33,00	1515,000	72,93	8,291	1,919	82,48	10,713	11,637
No.	27,78(20–54)	25,00/29,00	0,714***	73,33	7,395	0,169*	75,00	8,493	0,001*
* Independent samples t test, One-way ANOVA, One-way ANOVA (Welch’s test), * Mann-Whitney U, ***Kruskal-Wallis H, Tamhane's T²/Bonferroni a > b > c > d

Upon a review of the participants’ scale scores, women, participants with university level education, participants who did not live with family members, housewives, smokers, participants with AV fistula, and participants without chronic diseases had higher BDI scores. Participants, who lived with someone other than family members, unemployed, smoking participants, and participants with central venous catheter (CVC) had higher SCNI scores. DSI scores were higher in participants, who completed secondary education, lived with their spouse and children, who were retired, who did not smoke, used CVC, had a comorbid chronic disease, and had physical disabilities. The difference was statistically significant (p < 0.005) (Table 4).

Table 5

The relationship between scale scores and certain variables
		BDI^**	SCNI^*	DSI^**
Age	r	-,083	-,099	,394**
Age	p	,369	,282	<,001
Dry weight	r	,415**	,095	,071
Dry weight	p	<,001^b	,305	,443
BMI	r	,165	,116	-,069
BMI	p	,073	,211	,455
BDI^**	r	1,000	,081	,117
BDI^**	p	.	,379	,206
SCNI^*	r	,081	1,000	-,180*
SCNI^*	p	,379	.	,049^a
DSI^**	r	,117	-,180*	1,000
DSI^**	p	,206	,049^a	.

Correlation is significant at the 0.01 level (2-tailed), Correlation is significant at the 0.05 level (2-tailed).

^aPearson Corralation, ^b Sperman Correlation. .

Upon correlation analysis, there was a moderate positive correlation between dry weight and BDI and a weak negative correlation between DSI and SCNI. The difference was statistically significant (p < 0.005) (Table 5). There was no significant relationship between other scale scores.

This study aimed to investigate symptom management, depression status, and spiritual care needs in hemodialysis patients, and the results are discussed below in the light of the previous studies:

Upon a review of relevant literature, symptoms frequently reported in HD patients included dry mouth,(3) loss of appetite,(4) fatigue,(5) constipation,(6) and cough.(7) It was reported that symptom burden was higher in women, individuals with comorbid chronic diseases,(32) lower income,(33) and individuals without access to adequate social support.(34) Another symptom was depression, which was reported to be a more prevalent problem in women (35) and in individuals with lower education.(36) The availability of social support affects symptom burden and supports depression.(14) In particular, availability of family support reduced the likelihood that the HD patient would experience anxiety (15). It was suggested that likelihood of depression was higher in HD patients, who did not have a regular job. This may be because of the fact that it is important for individuals to meet their financial needs during the HD treatment process (37). One of the most important triggers of depression for HD patients is the vascular access route. Especially the AV fistula increases the level of depression in patients due to the pain felt during the intervention.(12, 13) These results are consistent with results of the present study. Nevertheless, while previous studies reported higher levels of depression in non-smokers (11) and HD patients with comorbid chronic diseases (38), the same were lower in the present study. This may be attributed to different sociocultural traits. The most prevalent symptoms reported by HD patients in this study were dry mouth, loss of appetite, fatigue, constipation, cough, and respiratory distress. These symptoms are important for HD patients and require symptom management. Therefore, it is important to ensure the adequacy of dialysis, to evaluate symptom management by nurses and to guide the patient in that regard.

The results of previous studies with different patient groups suggested that as the spiritual well-being of the patient increased, the symptoms related to the disease decreased.(8, 9) Faith is an important spiritual need for HD patients.(39) Patients can cope with a variety of problems by embracing spirituality.(18) Spiritual care can effectively reduce the level of depression in patients on HD.(17, 18) The support provided by nurses in this regard can make a great contribution to patients.(19, 20) Consistent with previous studies, the results of the present study indicated a negative correlation between DSI and SCNI in patients on HD. This is suggestive of the fact that meeting the spiritual care needs of HD patients can reduce the symptom burden. Therefore, spiritual support may prove to help this patient group with coping with their symptoms.

The symptom management scores of the patients are well below the average. The most prevalent symptoms in patients on HD included dry mouth, loss of appetite, fatigue, constipation, cough, and respiratory distress. All HD patients had depressive traits. The spiritual care needs of these patients are much higher compared to average. The most important results of this study were that all HD patients had depressive symptoms, symptom burden was higher, and the need for spiritual care was higher. There was a negative correlation between the need for spiritual care and symptom burden. It can be suggested that as the need for spiritual care is met, patients can cope better with dialysis symptoms. There is a correlation between depression and dry weight in patients on HD.

Recommendations

It would be a correct approach to regularly assess the depressive signs of patients on HD by nurses, to support them spiritually and to meet their spiritual care needs, to produce solutions for patients to cope with HD symptoms and to provide nursing care accordingly, to maintain the dry weight of patients, and to plan and implement nursing interventions for the most prevalent symptoms. Furthermore, raising the awareness of nurses and nursing students on this issue and future studies would be an important step to produce solutions for the future.

Author Contribution

ışın cantekin data collection, writtingrukiye burucu statistic, writting

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No competing interests reported.

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The Relationship between Symptom Management, Depression Status, and Spiritual Care Requirement in Hemodialysis Patients in Turkey: A Correlational Study

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Abstract

INTRODUCTION

METHOD

Population and sample

Sample

Inclusion criteria

Data Collection Forms and Data Collection

Socio Demographic Information Form

Beck’s Depression Inventory

Spiritual Care Needs Scale

Dialysis Symptom Index in Chronic Hemodialysis Patients

Data Collection

Variables of the Study

Ethical Dimension of the Research

Statistical Analysis

Results

Discussion

Conclusion

Recommendations

Declarations

Author Contribution

References

Additional Declarations

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