|Year : 2015 | Volume
| Issue : 2 | Page : 255-262
|Coping methods to stress among patients on hemodialysis and peritoneal dialysis
Kobra Parvan1, Ronak Ahangar1, Fahimeh Alsadat Hosseini2, Farahnaz Abdollahzadeh1, Morteza Ghojazadeh3, Madineh Jasemi1
1 Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Tabriz, Iran
2 Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
3 Department of Physiology, Tabriz University of Medical Sciences, Tabriz, Iran
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|Date of Web Publication||3-Mar-2015|
| Abstract|| |
Dialysis patients need to deal and cope with various aspects of their disease. Identifying the adaptation methods provides valuable information for planning specific treatment and medical care delivery and improving the performance of medical teams. The present study aims to evaluate the coping strategies to stress among patients undergoing hemodialysis (HD) and peritoneal dialysis (PD) at the Imam Reza Educational-Medical Hospital, Tabriz, West Azarbaijan, Iran. This descriptive and analytical study was conducted on 70 patients in the year 2012. The subjects were selected through census method and simple random sampling method. Data were collected using a customized questionnaire and consisted of demographic information and the Jalowiec Coping Scale (JCS) through a structured interview. Descriptive and inferential statistics were used to analyze the data in SPSS (version 13). The mean score of frequency of use of the coping strategy as "sometimes used" for the HD patients was 70.94 ± 18.91 and also for PD patients as "seldom used" was 58.70 ± 12.66. The mean score of helpfulness of coping strategies in the HD group was 49.57 ± 19.42 as "slightly helpful", whereas in the PD group it was 37.21 ± 14.38 as "slightly helpful" Furthermore, both groups used the emotion-oriented coping styles more frequently than the problem-oriented methods. HD patients used coping methods more frequently than the PD patients. The majority of patients used emotion-oriented coping strategies to deal with stress factors. Use of educational, counseling and supportive programs to assist in coping techniques can facilitate the coping process with stress factors in dialysis patients.
|How to cite this article:|
Parvan K, Ahangar R, Hosseini FA, Abdollahzadeh F, Ghojazadeh M, Jasemi M. Coping methods to stress among patients on hemodialysis and peritoneal dialysis. Saudi J Kidney Dis Transpl 2015;26:255-62
|How to cite this URL:|
Parvan K, Ahangar R, Hosseini FA, Abdollahzadeh F, Ghojazadeh M, Jasemi M. Coping methods to stress among patients on hemodialysis and peritoneal dialysis. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2019 Nov 18];26:255-62. Available from: http://www.sjkdt.org/text.asp?2015/26/2/255/152409
| Introduction|| |
End-stage renal disease (ESRD) is an irreversible clinical condition with loss of kidney function resulting in dependence on renal replacement therapy. , There are three types of renal replacement techniques, including hemodialysis (HD), peritoneal dialysis (PD) and kidney transplantation. 
According to a report of the Kidney Patients and Renal Transplantation Research Center in Iran, 2007, about 29,000 patients are suffering from chronic kidney failure in this country; 50% of them are receiving HD, 47.5% are receiving transplantation and the remaining 2.5% are undergoing PD. 
Each treatment method has some requirements, benefits and considerations.  They help patients with ESRD; however, they are considered as a source of stress.  HD treatment is highly inflexible and patients, in addition, need to cope with various aspects of their disease. These patients often have difficulty in coping with the disease's stress factors.  Typical HD stress factors include physical dependence on devices, limitations in physical function, changes in sexual function and diet, fluid restriction, taking large doses of drugs for treatment and loss of appetite and energy. Psychosocial stress factors include not having adequate time to perform dialysis, loss of job, loss of independence, changes in self-perception and fear of death.  Like HD, there are some stress factors for PD also. The complex therapy severely restricts the patients' activities in ambulatory PD and causes loss of independence, financial stress, changing roles, changing self-esteem and breakdown of family life. 
Coping with chronic illness is always a challenging and threatening process, and healthcare providers need to be aware of these conditions.  If coping strategies are used effectively, they can help in improving the performance and well being of individuals. Understanding the processes that dialysis patients pass through can help the health-care providers to efficiently manage their patients. ,
Studies on the coping strategies are required because of the following reasons: (a) The conflicting findings of the published studies on this topic, ,,, (b) the impact of cultural differences in experiencing stress factors in different communities  and (c) the limitations of the studies regarding the adaptation strategies, particularly in patients on PD. The current study aimed to evaluate the coping strategies of HD and PD patients.
| Materials and Methods|| |
An analytical, cross-sectional study was performed to evaluate the coping strategies at the Imam Reza Educational-Medical Hospital (Tabriz, Iran) among patients undergoing HD andPD in 2011.
Population and sample
The study patients included those undergoing HD and PD at the Imam Reza Educational-Medical Hospital, Tabriz, Iran. Census sampling was applied on HD patients and all interested patients were included in the study. Simple random sampling was applied for PD patients. A total of 70 patients undergoing HD and 70 other patients on PD were selected by the simple random sampling method.
Inclusion criteria included age ≥14 years, absence of cognitive impairment or psychological disease such as depression, absence of acute diseases, physical and mental capability to answer the questions, on hospital HD for at least six months and two to three times a week and PD for at least six months and four times replacement of the solution per day.
For data collection, a two-part questionnaire was used; personal-social characteristics and the Jalowiec Coping Scale. The first part consisted of six questions regarding the personal-social characteristics of HD and PD patients, including age, gender, job status, income, marital status and dialysis duration.
The second part comprised of the Jalowiec Coping Scale. The 60-item scale (representing eight coping styles) was applied to determine the coping strategies of dialysis patients.
The eight coping styles comprised of the following: Confrontive (10 items/strategies); evasive (13 items/strategies); optimistic (nine items/ strategies); fatalistic (four items/strategies); emotive (five items/strategies); palliative (seven items/strategies); supportive (five items/strategies) and self-reliant (seven items/strategies). Confrontive and supportive items were classified as problem-oriented coping styles. Evasive, optimistic, palliative, emotive, fatalistic and self-reliant items were attributed to emotion oriented coping styles. In the current study, 37 items were categorized as emotion-oriented coping styles and 23 as problem-oriented coping styles. Participants answered each item in two ways: (a) frequency of use and (b) perceived helpfulness. In this regard, the questionnaire consisted of two parts, A and B.
Part A consisted of questions related to frequency of use of coping strategies (never, seldom, sometimes and often) based on a four-item scale. The score of each of the response was 0 to 3. The scores ranged from 0 to 180. In part A of the questionnaire, a total score of 0 meant "never used," 1-60 meant "seldom used," 61-120 meant "sometimes used" and 121-180 meant "often used." The highest score showed the highest rank of coping strategies. Part B was dedicated to the questions on quality of the coping strategies by the patient. The answers included helpful, slightly helpful, fairly helpful and very helpful. The scores were based on a four-item scale. The score of each of the response was 0-3. The scores ranged from 0 to 180. In part B of the questionnaire, a total score of 0 meant "not helpful," 1-60 meant "slightly helpful," 61-120 meant "fairly helpful" and 121-180 meant "very helpful." The highest score showed the highest rank of coping strategies.
The validity and reliability of the questionnaire has been assessed in other studies. Twenty-five nurse researchers familiar with the literature about stress and coping methods approved the Jaloweic's Coping Scale. , A Cronbach's Alfa coefficient of 0.86 for total questionnaire was obtained in the study of Burns. 
However, the validity and reliability of the questionnaire has not been studied in the Iranian society. A forward-backward translation method was used to translate the original English version of this questionnaire to Persian language. A literature review and standard questionnaire was utilized to assess the validity of the instrument. Also, a total of seven faculty members of nursing and midwifery schools of the Tabriz University Medical Sciences assessed the intelligibility of the instrument's content. Revisions were made according to the suggestions received. The reliability of the data collection measure was determined using test-retest. Ten eligible patients were interviewed, and, after two weeks, the same people were interviewed again. The responses were then compared and the correlation coefficient was measured. The correlation coefficient of the Jalowiec Coping Scale was 0.81.
The data were collected using a structured interview by the questionnaire. The researcher was referred to the HD and PD departments of the Imam Reza Educational-Medical Hospital, Tabriz, Iran to interview the patients and ask them to complete the questionnaires.
Approval of the current study was obtained from the Research Deputy of the Nursing School of the Medical Sciences of Tabriz University and the Ethical Committee. Because the data collection method was based on interview, patients were explained about the study details and full confidentiality of the information was ensured. Also, return of the completed questionnaire was identified as giving consent to participate in the study.
The data were analyzed using statistical package of SPSS (version 13). Descriptive statistics (frequency, percent and mean and standard deviation) and non-parametric inferential statistics (Kruskal-Wallis, U-Mann-Whitney) and Spearman correlation coefficient were applied. The significance level was P <0.05.
| Results|| |
The demographic characteristics of the patients who participated in the study are presented in [Table 1]. The priority of coping strategies based on the most frequent use and helpfulness in patients undergoing HD and PD are shown in [Table 2] and [Table 3].
|Table 2: Respective ranking for "use" and "helpfulness" of items from the Jalowiec coping scale, based on highest mean scores in hemodialysis patients (N = 70).|
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|Table 3: Respective ranking for "use" and "helpfulness" of items from the Jalowiec Coping Scale based on the highest mean scores in peritoneal patients (N = 70).|
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The mean score of usage of coping strategies in the HD group was 70.94 ± 18.91 as "sometimes used." The mean score of usage of coping strategies in the PD group was 58.70 ± 12.66 as "seldom used."
About the helpfulness of the applied coping strategies, the mean score of the HD group was 49.57 ± 19.42 as "slightly helpful." The mean score of the PD group was 37.21 ± 14.38as "slightly helpful."
The U-Mann-Whitney test showed a significant difference between the use of coping strategies and the helpfulness of coping strategies in the two groups of dialysis patients. The use and helpfulness of coping strategies in HD patients were more than in patients undergoing PD [Table 4].
|Table 4: The comparison of the mean score of the use and helpfulness of coping strategies in hemodialysis and peritoneal dialysis patients at the Imam Reza Educational-Medical Hospital (Tabriz, Iran), 2011.|
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The Spearman correlation test showed a direct and strong relationship between the use and helpfulness of the coping methods in both groups [Table 5]. There was a weak and negative correlation between age of the patient and use of coping strategies in HD patients. The older the patient, the lower was the use of coping strategies (r = -0.31, P = 0.008). Similar findings were seen among PD patients as well; older the patient, lower was the use of coping strategies (r = -0.23, P = 0.05). There was no significant association in the other variables.
|Table 5: The association between the score and the effect of coping strategies among hemodialysis and peritoneal dialysis patients at the Imam Reza Educational-Medical Hospital (Tabriz, Iran), 2011.|
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| Discussion|| |
The present study aimed to evaluate the coping strategies in two groups of patients undergoing HD and PD. Also, the association between the methods was compared in the two groups of patients.
Among the 10 most frequently used components, the highest coping strategy in both groups was "Prayer and trust in God." Like the present study, in many previous studies, "Prayer and trust in God" has been rated highly in HD patients. ,, One of the most important coping strategies of PD patients in the study of Zimmer was "Prayed or put your trust in God." 
Generally, in the present study, the religious aspect, including praying or trust in God, was the most frequently used and helpful coping strategy in HD and PD patients; this is largely related to the prominent position of religious beliefs in the culture and life of Iranian people.
The mean score of dialysis patients (HD and PD) regarding the use and helpfulness of emotion-oriented coping strategies was higher than problem-oriented coping methods. Based on the studies performed by many researchers, it was found that HD and PD patients use the emotion-oriented styles more often in coping with the challenges and stresses related to the disease and treatment. ,,,, The findings of the present study are in accordance with the results of many previous studies. However, the study performed by Ghaffari et al showed that the majority of HD patients used problem-oriented coping strategies to deal with stress factors;  this finding is inconsistent with the results of the current study. The reasons for the discrepancy between these findings can be the different research methodology used as well as the different study population.
In this study, patients on HD and PD used coping methods "sometimes" and "seldom," respectively, for coping with the existing conditions. Coping methods were slightly helpful in both groups of patients, and emotion-oriented coping strategies were more frequently used than problem-oriented coping methods by both groups of dialysis patients. In earlier studies,  problem-oriented styles were more helpful than emotion-oriented styles in dealing with stress factors. On the other hand, according to Miller, the emotion-oriented coping mechanism is used when the stress events cannot be controlled with other methods.  However, limited use of the problem-oriented coping strategies by the patients can, at times, be due to lack of patients' knowledge on the helpfulness of these mechanisms in stress management. Additionally, because the individuals are not required to learn and apply special skills to use specific emotion-oriented coping strategies, problem-oriented coping methods are rarely adapted. Thus, organized planning and training as well as assessment of problem-oriented coping strategies in patients are required.
There was a significant association between the use and helpfulness of coping strategies in both groups. Their use was more beneficial in the HD patients than in the PD patients. Previous studies have shown that patients treated with HD experience significantly higher stress levels than patients undergoing PD (P <0.001). , Goker showed that 65.2% of HD patients had an associated psychiatric disorder, the most common being depression and/or anxiety. , Studies have shown that the level of depression among patients undergoing HD was higher than in patients undergoing PD. ,,, It could be because PD is less invasive and less restrictive than HD. 
In the current study, there was a strong and direct association between the use and helpfulness of coping strategies in both patent-groups. Despite the frequent use of emotion-oriented coping strategies, indeed greater use of coping strategies (emotion-oriented or problem-oriented coping methods) was found to lead to higher and helpful coping strategies in both groups of dialysis patients.
We also found that with an increase in the age in patients treated with PD or HD, the use of coping strategies was significantly lower. In the study performed by Logan et al and Cheng et al, similar results were obtained in patients undergoing HD and PD. , It is likely that with the increase in age, several factors including progression of the disease, complications related to physical and psychological aspects and developmental stage of the person and other important factors might play an important role in the lack of adequate use of the coping methods.
The present study has several limitations, including the large number of questionnaire items, fatigue and physical and psychological conditions of patients that might have affected how the participating patients responded. Because the current study was conducted on patients undergoing HD and PD at the Imam Reza Hospital (Tabriz, Iran), the results cannot be generalized to other dialysis patients. Therefore, it is recommended that further studies be performed on a larger sample size of dialysis patients.
| Conclusions|| |
The majority of patients in the current study used emotion-oriented coping strategies to deal with the stress factors. Although many of the emotion-oriented coping strategies were identified as helpful coping strategies by the patients, because the problem-oriented coping strategies are more difficult to respond, these methods were not adequately applied, which could be due to lack of knowledge among the patients. Furthermore, considering the importance of understanding all aspects of stress factors and coping strategies, regular psychiatric assessment and counseling could facilitate the coping process of dialysis patients with the stress factors and lead to improvement in the quality of life as well as promoting physical and mental health of these patients.
Conflict of interest: None declared.
Neither this manuscript, nor one with substantially similar content under my authorship, has been published or is being considered for publication elsewhere, and all the data collected during the study is presented in this manuscript and no data from the study has been or will be published separately.
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Fahimeh Alsadat Hosseini
Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Student Research Committee, Shiraz University of Medical Sciences, Shiraz
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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