| Abstract|| |
Individuals who care for family members receiving chronic hemodialysis (HD) are likely to experience burdens that may adversely impact their patients. Effective coping strategies are shaped by various factors, including sociodemographic characteristics. To assess the relationship between caregivers and their patients, we studied 225 family-member caregivers of chronic HD patients through answering the Ways of Coping Questionnaire-Revised. Sociodemographic data, including caregiver age, gender, educational level, relationship to the patients, length of care time and weekly hours of caregiving were analyzed using the t-test, analysis of variance and least-significant difference post hoc test. Of the eight coping strategies investigated, seven were significantly related to at least one of the analyzed sociodemographic variables; these were confrontive coping, distancing, self-controlling, seeking social support, accepting responsibility, planful problem solving and positive reappraisal. The findings of the present study may be useful for administering dialysis by nurses for identifying coping strategies among caregivers and for establishing plans of care that would promote coping strategies in relation to the caregiver's sociodemographic characteristics.
|How to cite this article:|
Alnazly E. Coping strategies and socio-demographic characteristics among Jordanian caregivers of patients receiving hemodialysis. Saudi J Kidney Dis Transpl 2016;27:101-6
|How to cite this URL:|
Alnazly E. Coping strategies and socio-demographic characteristics among Jordanian caregivers of patients receiving hemodialysis. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2019 Sep 18];27:101-6. Available from: http://www.sjkdt.org/text.asp?2016/27/1/101/174088
| Introduction|| |
Most patients receiving hemodialysis (HD) rely on family members to assist with daily living and medical care, and the role of the family caregiver can be substantial in scope. Caregivers also provide emotional and psychosocial support for patients coping with HDrelated stressors. , In Jordan, the number of patients receiving HD is increasing annually, and reached 4,272 in 2013. 
Coping has been conceptualized as changes in cognition and behavior to deal with stressful events. The transaction model of stress and coping suggests that the coping strategies employed depend on the caregiver's appraisal of a stressful situation. 
Several sociodemographic factors impact coping strategies of caregivers of chronically ill patients. Coping in the face of sociodemographic variables such as income and living with care recipients is a significant burden on caregivers. , Onwumere et al  investigated avoidance coping in caregivers of psychotic patients and found no association with caregiver sociodemographic variables (sex, age or living with patients). The family income of parents of children waiting for a kidney transplant was negatively correlated with avoidance coping.  Highly educated parents of mentally ill children likely found "understanding the medical situation" more helpful than parents with lower educational levels. 
Although previous studies have assessed caregiver coping strategies, few have focused on the relationship between the sociodemographic factors and strategies of caregivers of HD patients. Given the paucity of data, the purpose of the current study was to identify coping strategies used by Jordanian caregivers of HD patients and to assess their relationship with caregiver sociodemographic variables to determine how much variability in coping strategies can be explained by the sociodemographic characteristics.
| Patients and Methods|| |
Individuals who provided the majority of the care (caregivers) to HD patients were invited to participate in this study. The caregivers willing to participate were introduced to the principle investigator.
For a caregiver to be included in the study, he/she had to be (a) an unpaid family member, (b) identified by the patient undergoing HD as the individual who provided the most care for him or her at home, (c) at least 18 years of age, (d) able to read and write Arabic, (e) caring for a patient undergoing HD currently and for at least one year and (f) participating in the study voluntarily.
After approval of all procedures by the research ethics boards of all hospitals where the dialysis units existed, the participants were given a comprehensive explanation of the purpose of the study. After both patients and caregivers provided signed informed consents, questionnaires were provided to the caregivers. Of 230 questionnaires distributed, 225 were returned to the dialysis units by the patients.
Data were collected for each caregiver/participant using a sociodemographic characteristics data sheet and Ways of Coping Questionnaire-Revised (WCQ-R).  The sociodemographic information obtained included the caregiver's gender, age, education, years of caregiving, hours of caregiving/week and relationship to the patient. The WCQ-R was employed to identify and measure the various coping strategies employed by the caregivers. This tool consists of 66 items scored on a 4-point Likert scale and includes eight coping subscales: confrontative coping, distancing, selfcontrolling, seeking social support, accepting responsibility, escape avoidance, planful problem solving and positive reappraisal. The response scale ranges from 0 to 3, with 0 indicating "not used," 1 indicating "used somewhat," 2 indicating "used quite a bit" and 3 indicating "used a great deal." The reliability of eight subscale scores ranges from 0.60 to 0.75.  In this study, the reliability ranged from 0.66 to 0.75.
| Statistical analysis|| |
All statistical data were analyzed using the Statistical Program for Social Sciences version 22.0 (SPSS Inc., Chicago, IL, USA). The relationships between the caregivers' coping strategies and the sociodemographic characteristics were analyzed using the t-test, analysis of variance (ANOVA) and least significant difference (LSD) post hoc.
| Results|| |
[Table 1] shows the sociodemographic characteristics of the caregiver/participants. Nearly two-thirds of the patients and 67.0% of the caregivers were male. More than half were <30 years of age and had achieved an educational level of 12-16 years. More than two-thirds of the caregivers had been providing care for the patients undergoing HD for <5 years, with 41.8% providing care for <40 h/week and 22.2% providing care for >80 h/week. Different types of family members cared for the HD patients, including the child (son or daughter, 44.9%) and the spouse and other relatives who comprised about 25% of the respondents.
Distancing was the only coping strategy that varied significantly by gender (t = 2.69, P = 0.008), with males using this strategy more commonly than females. The three most frequently used coping strategies were self-controlling, positive reappraisal and planful problem solving. Confrontive coping and escape avoidance were the least frequently used coping strategies.
ANOVA of the use of coping strategies by caregiver age revealed a significant difference in coping strategies by age only for confrontive coping (F = 5.149, P = 0.007) and accepting responsibility (F = 3.068, P = 0.049). LSD post hoc analysis of use of the strategies confrontive coping and accepting responsibility based on caregiver age shows that caregivers 30-45 years of age and >45 years of age used these strategies more often than those aged <30 years of age.
ANOVA of use of coping strategies by the level of education shows that only two coping subscales were significantly different in terms of the level of caregiver education, distancing (F = 3.573, P = 0.015) and self-controlling (F = 2.476; P = 0.049). LSD post hoc analysis was conducted to explore in more detail the statistically significant associations between education level and the distancing and selfcontrolling subscales. A lower educational level was associated with more frequent use of distancing and self-controlling than a higher educational level.
ANOVA showed that only two coping subscales were significantly different based on the caregiver's relationship to the patient, selfcontrolling (F = 3.025, P = 0.30) and seeking social support (F = 2.638, P = 0.05); LSD post hoc analysis showed that the strategy of selfcontrol was used more commonly by the son/daughter than by the spouse, and the spouse tended to seek support more than others.
ANOVA showed that only two coping subscales varied significantly by the length of time the caregiver had been providing care; these were accepting responsibility (F = 3.207, P = 0.042) and positive reappraisal (F = 3.834, P = 0.023). The LSD post hoc analysis showed that the longer the caregivers provided care, the more they used accepting responsibility and positive reappraisal as coping strategies.
ANOVA showed that only one coping strategy, planful problem solving, differed significantly between groups based on hours of caregiving/week (F = 10.18, P = 0.00). LSD post hoc revealed that increasing hours of care provided caused an increase of the caregivers' use of planful problem solving.
| Discussion|| |
Our study examined the coping strategies of caregivers of patients receiving HD in relation to socio-demographic characteristics. Here, 63% of all caregivers were male, consistent with the findings of Winter et al,  but in contrast to those of the National Alliance for Caregiving,  which reported 66.0% of female caregivers in the USA. The preponderance of male caregivers matched that of the patients. Under local Jordanian customs, male caregivers provide male patients with personal care, whereas females provide these patients with housekeeping services only.
Of the respondent caregivers, 86.7% were 21-45 years of age, in contrast to an American study where 51.0% were18-49 years of age.  This discrepancy might be related to the composition of the general Jordanian population, of which 41.8% is 20-49 years of age, or to the custom that children provide direct care for a sick family member.  On the other hand, the number of hours spent caregiving were similar to those in the American study, where 41.8% provided <40 h/week and 36.0% provided 40-80 h of weekly care.
In our study, the most common strategy used by the male caregivers was distancing, consistent with previous reports elsewhere.  Distancing is cognitive detachment from the caregiving responsibility, when caregivers "go on as if nothing happened" and "try to forget the whole thing." However, some response items showed an element of positive outlook, whereby a caregiver "tried to look on the bright side." Nevertheless, the caregiver of a patient receiving HD may experience psychological distress from using distancing as a coping strategy. We recommend educating the caregivers, especially males, on essential caregiving tasks.
Our study showed that adults aged >30 years preferred the more emotion-focused strategy (accepting responsibility) compared with younger adults. The older adults used accepting responsibility and confrontive coping (problem-focused) strategies crucial for effective coping. However, this age group made more use of coping strategies that might suit the caregiving tasks' (nutrition, toileting, personal care, mobility and other support service) problems. We recommend nursing interventions to identify coping strategies that effectively employ both emotion-focused and problem-focused coping.
The current study showed that a lower education level was associated with the emotionfocused strategies distancing and self-controlling compared with a higher level of education. Caregivers appeared to distance themselves from stress-provoking events and controlled themselves to avoid stress. Although these strategies have a calming effect on caregivers, they do not increase caregiver contort level and are effective only temporarily. If their effects lasted longer, these strategies might result in maladaptive coping, leading to a stressful lifestyle. We recommend nursing interventions to educate caregivers on effective coping strategies, including selfcontrolling and distancing.
Family caregivers are emotionally involved with their care recipients and perceive a higher level of stress than non-family caregivers.  Schuster et al  suggest that social support reduces the perception of stress, facilitating coping. In their study, the spouse of the caregiver experienced emotional stress with regard to the caregiving tasks. However, spouses used the available resources from family, friends, relatives and other social networks that are necessary to help their spouse cope with the caregiving stress.
Non-spouse caregivers used self-control. In our study, self-controlling and seeking social support were coping strategies unique to those providing care to family members. Spouses may be more apt to accept the responsibility of proactively seeking support, whereas other family caregivers reacted to perceived stress by a self-controlling strategy via not showing the stress they are experiencing. In either case, caregivers confidently evaluated their stressful situations and attempted to use effective adaptive strategies.
In our study, caregivers used accepting responsibility and positive reappraisal strategies with an increase in weekly caregiving time. Caregivers acknowledged their roles and reduced the negative emotional aspects of the situation and made an effort to adopt a positive outlook with regard to it. Nurses should be alert to the likelihood that hardship among family caregivers might intensify during the period of caregiving. Nurses should initiate educational programs that encourage problemfocused coping that will result in positive outcomes.
Our study revealed that caregivers who spent more hours/week caregiving tended to use planful problem solving. A caregiver appraises the caregiving task as changeable and deliberately elects to use planful problem-solving coping strategies to alter the situation. This strategy allows for greater adaptability to facilitate improvement of specific stressful situations. Such efforts have a positive impact on the wellbeing of both the caregiver and the patient.  A coping strategy based on planful problem solving will improve both perception of and intervention in the stressful situations. However, nurses should be cautious in situations where the source of stress cannot be altered or may result in more distress.
In conclusion, the findings of this study provide an insight into the characteristics of caregivers of HD patients and the means they use to cope with the stress of caregiving. The findings show that gender, spousal relationship and hours spent with patients influence caregiver coping style. Males employed distancing coping strategies more commonly than females, and a lower educational level was associated with more frequent use of distancing and self-controlling. Caregivers who spent more hours with the patient employed planful problem solving to a greater extent than caregivers spending fewer hours. Spouses are more likely to employ seeking social support. Programs providing information on available resources and strategies for navigating the health care system may be beneficial for these subpopulations. Training in problem-solving skills might also be beneficial.
Further research is needed to explore how these differences in coping responses impact family adaptation to patient health outcomes as these results have implications for clinical practice.
| Acknowledgments|| |
The author would like to thank the patients, families and health care professionals and administrative personnel at the dialysis units for participating in the study.
Conflict of Interest: None declared.
| References|| |
Ferrario SR, Zotti AM, Baroni A, Cavagnino A, Fornara R. Emotional reactions and practical problems of the caregivers of hemodialysed patients. J Nephrol 2002;15:54-60.
Morton RL, Tong A, Howard K, Snelling P, Webster AC. The views of patients and carers in treatment decision making for chronic kidney disease: Systematic review and thematic synthesis of qualitative studies. BMJ 2010;340:c112.
Tarawneh M, Al-Qaisi S. Bi-Annual Report 2009-2010. Amman: Hashemite Kingdom of Jordan Ministry of Health; 2011.
Folkman S, Lazarus RS. If it changes it must be a process: Study of emotion and coping during three stages of a college examination. J Pers Soc Psychol 1985;48:150-70.
Kim H, Chang M, Rose K, Kim S. Predictors of caregiver burden in caregivers of individuals with dementia. J Adv Nurs 2012;68: 846-55.
Papastavrou E, Kalokerinou A, Papacostas SS, Tsangari H, Sourtzi P. Caring for a relative with dementia: Family caregiver burden. J Adv Nurs 2007;58:446-57.
Onwumere J, Kuipers E, Bebbington P, et al. Coping styles in carers of people with recent and long-term psychosis. J Nerv Ment Dis 2011;199:423-4.
Zelikovsky N, Schast AP, Jean-Francois D. Parent stress and coping: Waiting for a child to receive a kidney transplant. J Clin Psychol Med Settings 2007;14:320-9.
Liu M, Lambert CE, Lambert VA. Caregiver burden and coping patterns of Chinese parents of a child with a mental illness. Int J Ment Health Nurs 2007;16:86-95.
Folkman S, Lazarus RS. Ways of Coping Questionnaire. Research Edition. Palo Alto, CA: Consulting Psychologists Press Inc.; 1988.
Rexrode KR, Petersen S, O′Toole S. The ways of coping scale: A reliability generalization study. Educ Psychol Meas 2008;68:262-80.
Winter L, Gitlin LN, Dennis M. Desire to institutionalize a relative with dementia: Quality of premorbid relationship and caregiver gender. Fam Relat 2011;60:221-30.
Lazarus RS, Folkman S. Stress, Appraisal, and Coping. New York: Springer; 1984.
Schuster RM, Hammitt WE, Moore DA. Theoretical model to measure the appraisal and coping response to hassles in outdoor recreation settings. Leis Sci 2003;25:277-99.
DeLongis A, Newth S. Coping with stress. In: Friedman HS, eds. Assessment and Therapy. San Diego, CA: Academic Press; 2001. p. 139-49.
Nursing Faculty, Amman Al-Ahliyya University, P.O. Box 19328, Amman