Examinations of effects of socio-demographic features and disease-related data of patients with hemodialysis on the quality of life

This study aimed to detect the effects of demographic features and disease-related data of individuals with hemodialysis treatment on quality of life. The research universe consisted of 113 patients who received dialysis treatment in three state hospitals. Sampling was not used in this research with 97 volunteer patients who complied with the study criteria. The data collection process was performed face-to-face between 1 May and 30 June 2020. Data was collected using the Participant Information Form and the Quality of Life Scale (Short From-36). In our research, 50.5% of participants were male and 49.5% were female. The age of 61.9% of participants was ≥ 51 years and 78.4% were married. Most participants (67%) had ≥ 3 children, 35.1% received dialysis treatment for 3–10 years, 90.7% had dialysis three times a week, and 64.9% had an arterio-venous fistula vascular access line. In addition, 24% had another family member who received dialysis treatment, with hypertension as the etiology in 35.6% of chronic renal failure (CRF). The findings showed that 93.8% patients had no previous transplantation, and 62.9% considered future transplantation.Within the scope of this research, the findings suggest that the quality of life of dialysis patients was poor. Demographic features and disease data affected the quality of life at different levels.


Statistical analysis
Data obtained from this study were analyzed with the SPSS (Statistical Program in Social Sciences 25) program.Mann Whitney U test was used to compare scores obtained by the SF-36 quality of life Scale according to twocategory variables (e.g., gender).Kruskal Wallis H test was used to compare scale scores according to more than two-category variables (e.g., age groups).Dual comparisons were made to detect the origin of the difference and Bonferroni correction was performed.In the scope of this research, the Shapiro-Wilk normality test was used to examine the distribution of scores obtained with the SF-36 quality of life scale.The confidence interval for analysis was set as 95%, and p < 0.05 was noted as statistically significant.

Results
As shown in Table 1, 49.5% and 50.5% of participants were female and male, respectively.Most participants (61.9%) were in the ≥ 51 years of age group and 78.4% of participants were married.Most participants (67%) had ≥ 3 children.Also, 47.4% of participants lived in nuclear and 52.6% were in large families; 34% of the www.nature.com/scientificreports/participants were illiterate, 15.5% were literate, and 30.9%, 17.5% and 2.1% were in elementary schools, high school and bachelor's degree graduate, respectively.
As shown in Table 2, 16.5% of participants received dialysis treatment for 0-1 year, 27.8% for 1-3 years, 35.1% for 3-10 years and 20.6% > 10 years.Most participants (90.7%) received dialysis three times a week.Thirty-two percent had a permanent tunneled catheter, 3.1% had a temporary tunneless catheter and 64.9% had arterio-venous fistula vascular access lines.In addition, 24% of participants stated that there was another family member who received dialysis treatment.Those who received treatment as a family member are more likely the first (46.4%)and second-degree (39.3%) relatives relatives.About eighty-five percent of participants claimed they know about CRF.In this study, according to participants, the etiology of CRF were hypertension (HT) (35.6%), others (31.1%) and Diabetes Mellitus (DM) (25.6%) and 93.8% stated that they were not previous transplant recipients.Also, 62.9% considered a future transplantation (Table 2).
Physical functioning, physical role function, emotional role function, and social functioning scores were not significantly different according to gender (p > 0.05).Nevertheless, energy/fatigue/vitality, mental health, pain and general health perception scores were significantly different according to gender (p < 0.05).Scores of energy/fatigue/vitality, mental health, pain and general health perception were significantly higher in males than females (Table 3).
Physical role function, emotional role function, energy/fatigue/vitality, mental health, and social functioning pain and general health perception scores were not significantly different according to age groups (p > 0.05).However, physical function scores were significantly different according to age groups (p < 0.05).Physical function scores of participants in ≤ 30, 31-40 age and 41-50 age groups had significantly higher scores than ≥ 51 age group (Table 3).
Physical function, physical role function, emotional role function, energy/fatigue/vitality, mental health, and social functioning, pain and general health perception scores were not significantly different according to marital status ( p ≥ 0.05).Physical function, physical role function, emotional role function, energy/fatigue/ vitality, mental health, social functioning, pain and general health perception were similar between married and single participants (Table 3).
Emotional role function, energy/fatigue/vitality, mental health, pain and general health perception scores were not significantly different according to the number of children (p > 0.05).Nonetheless, physical function, physical role function and social functioning scores were significantly different according to the number of children (p < 0.05).Physical function and physical role function scores of those without children and with 1-2 children www.nature.com/scientificreports/were significantly higher than those with ≥ 3 children.Social functioning scores of those without children were significantly higher than those with 1-2, and ≥ 3 children (Table 3).As shown in Table 3, physical function, physical role function, emotional role function, energy/fatigue/vitality, mental health, social functioning, pain and general health perception scores were not significantly different according to family type (p > 0.05).Participants of a nuclear and large family had a similar physical function, physical role function, emotional role function, energy/fatigue/vitality, mental health, social functioning, pain and general health perception.
It was understood that emotional role function, social functioning and general health perception scores were not significantly different according to educational status (p > 0.05).However, physical function, physical role function, energy/fatigue/vitality, mental health and pain scores were significantly different according to educational status (p < 0.05).The physical function score of high school & bachelor's degree graduate participants was significantly higher than those of illiterate, literate and elementary school graduates.On the other hand, energy/fatigue/vitality, mental health and pain scores of high school & bachelor's degree and elementary school graduates were significantly higher than those of illiterate and literate participants (Table 3).
When Table 4 is examined regarding duration of dialysis treatment, 16.5% of participants had 0-1 year, 27.8% had 1-3 years, 35.1% had 3-10 years and 20.6% had > 10 years.Most participants (90.7%) received dialysis three www.nature.com/scientificreports/times a week.Thirty-two percent of participants had a permanent tunneled catheter, 3.1% had a temporary tunneless catheter and 64.9% had arterio-venous fistula vascular access lines.According to Table 4, 24% of participants expressed that they had other family members receiving dialysis treatment.It was understood that other family members who received dialysis treatment were most likely first (46.4%)and second-degree (39.3%) relatives.The findings showed that 85.6% of participants expressed that they knew about CRF.Participants with CRF suggested that etiology was HT in 35.6%, other in 31.1% and DM in 25.6% of participants.About ninety-four percent had no previous transplantation history, and 62.9% considered future transplantation.
Physical function, physical role function, emotional role function, energy/fatigue/vitality, mental health, social functioning, pain and general health perception scores were not significantly different according to the duration of dialysis treatment (p > 0.05) as 0-1 year, 1-3 years, 3-10 years and 10+ years (Table 4).
Physical function, physical role function, emotional role function, energy/fatigue/ vitality, mental health, social functioning, pain and general health perception scores significantly different were not significantly different according to the frequency of weekly dialysis (p > 0.05).Participants who received dialysis in < 3 times a week and ≥ 3 times a week were similar regarding physical function, physical role function, emotional role function, energy/fatigue/vitality, mental health, social functioning, pain and general health perception (Table 4).www.nature.com/scientificreports/When Table 4 is examined, physical function, physical role function, energy/fatigue/vitality, mental health, social functioning, pain and general health perception scores were not significantly different according to the vascular line (p > 0.05).However, the emotional role function score was significantly different according to the vascular line (p < 0.05).The emotional role function score of participants with temporary tunneless catheter vascular lines was significantly higher than those with a permanent tunneled catheter vascular line.
Moreover, physical function, physical role function, energy/fatigue/vitality, mental health, social functioning, pain and general health perception scores were not significantly different according to the presence of a member of the family who received dialysis treatment (p ≥ 0.05).However, emotional role function scores were significantly different according to the presence of a member of the family who received dialysis treatment (p < 0.05).The emotional role function score of the participants who had other individuals who received dialysis treatment in their families was higher than those who did not have any individuals without treatment (Table 4).www.nature.com/scientificreports/As seen in Table 4, physical function, physical role function, emotional role function, energy/fatigue/vitality, mental health, social functioning, pain and general health perception scores were not significantly different according to the state of knowing the etiology of CRF (p > 0.05).Physical function, physical role function, emotional role function, energy/fatigue/vitality, mental health, social functioning, pain and general health perception were similar according to the state of knowing and not knowing the etiology of CRF.
As shown in Table 4, physical role function, emotional role function, energy/fatigue/vitality, mental health, social functioning, pain and general health perception scores were not significantly different according to the state of previous transplantation (p > 0.05).However, the physical function score was significantly higher according to the state of the previous transplantation ( p < 0.05).
Physical role function, emotional role function, energy/fatigue/vitality, mental health, social functioning, pain and general health perception scores were not significantly different according to the state of considering future transplantation (p > 0.05).However, the physical function score was significantly higher according to the state of considering future transplantation (p < 0.05).

Discussion
CRF is a critical important life-threatening public health problem seen in almost every age group, that may cause loss of labor force and comorbidity, which leads to dependency on dialysis centers and health personnel, which affects the quality of life due to dialysis complications.Socio-demographic variables like gender, age, educational status and many children significantly affect the quality of life [18][19][20][21][22] .
In our research, 50.5% and 49.5% of participants were male and female, respectively.Gender is an important factor that affects the level of a patient's quality of life 23 .The male gender had significantly higher energy/fatigue/ vitality, mental health, pain and general health perception scores.In studies with findings consistent with our research, it was stated that male patients who received dialysis had higher quality of life 24 .However, there are several contradictory studies in the literature.In the research of Akyol Durmaz et al. ( 2016), it was reported that the level of quality of life was similar in male and female patients 14 .
Although several studies suggested a higher quality of life for female participants, to our knowledge, no study examined the reasons.Despite the lack of certain outcomes, the reasons for poor quality of life in women might be their intense role in domestic life and cultural and social structure.This might be associated with females' poor options for nutrition and accommodation in Eastern societies, distress, anxiety and depression due to delivering many children.Women who have an intense role in domestic life should perform their duties whether they work or not.In addition, having a chronic disease makes life for women unbearable.Under all these circumstances, poor quality of life is inevitable 25 .
In our study, 61.9% of participants were ≥ 51 years of age.At the end of this research, it was seen that as age increased the average physical function score of the quality of life decreased.It was determined that the physical function scores of participants in the ≤ 30, 31-40 and 41-50 age range groups were higher than the ≥ 51 age group.In their study that examined the quality of life of patients with CRF(1), Atasoy et al. 1 obtained similar findings.Kaner et al. examined the quality of life of hemodialysis patients and related factors, and they found that patients younger than 65 years had a lower quality of life 22 .There are many similar studies 26,27 .Some studies have not revealed any relationship between age and quality of life.However, it has been suggested that age affects the quality of life 28 .
We shoul note that although age is an irreversible process, it is a state in which loss of physical function is at the forefront.Poor quality of life with increasing age is inevitable, keeping in mind the thought that as age advances various chronic diseases develop and physical restrictions accompany them 29 .We found consistent results in our research.
According to research results, 78.4% of participants were married.However, there was no significant relationship between the quality of life of being married and single.Similar and contradictory studies are present in the literature.In 2016, Durmaz Akyol 14 stated that 72.4% of participants were married, and married participants had higher quality of life scores.However, Kring & Crane 30 reported that there was no significant relationship between marital status and quality of life scores.This may be related to a woman's place in society, cultural life and woman's role.
The majority of participants (67%) stated that they had ≥ 3 children.Physical function and physical role function scores of those who did not have a child and had 1-2 children were significantly higher than those with ≥ 3 children.Social functioning scores of participants without children were significantly higher than those with 1-2, 3 and more children.In the literature, to our knowledge, there is no study about having children and the number of children.However, our study results indicated that the quality of life scores was higher in participants with children.This might be related to the thought that the presence of children provides a chance for care and support.
The findings showed that 34% of participants were illiterate.As an important factor that affects the quality of life, educational status has a direct impact on an individual's self-development, having a job and the nature of the job.According to the research results, it was suggested that individuals with high educational status had higher income, more social opportunities and thus higher quality of life 29 .We had consistent results.Physical function scores of high school and bachelor's degree graduate participants were significantly higher than those of illiterate, literate and elementary school graduates.Participants with high school, bachelor's degrees and elementary school graduates had significantly higher energy/fatigue/vitality, mental health and pain scores than illiterate and literate participants.
According to research data of Bayın Donar, 37.8% of patients were high school and 35.4% were middle school graduates.9.8% were illiterate 19 .In research, conducted in 2017 by the Department of Health Technology Evaluation, the findings showed that 52% of participants were middle school graduates and 23% were illiterate 31 .As a result of these studies, it was determined that patients' educational status positively and significantly affected their adaptation to the disease course, their disease-related perceptions and levels of their quality of life 32 .
Data from our research indicates that there was no statistical relationship between the quality of life and the duration of dialysis.The findings showed that 35.1% of patients had been receiving dialysis treatments for 3-10 years.In Gökalp & Arpacı's study with 324 patients, it was found that 50.6% of patients had been receiving dialysis treatment for six months to 1 year 32 .This findings suggests that the need for dialysis treatment is currently increasing.Together with an increasing number of patients in need of dialysis, a drop in the level of quality of life is inevitable.In our research, we found that 10 general scores of individuals with ≥ 10 years of dialysis treatments were low.There are similar and contradictory studies in the literature.In some studies, it has been suggested that there is no relationship between years of dialysis and quality of life scores 14 .However, in some other studies a relationship has been suggested 33 .
In our research, it was determined that 90.7% of participants had dialysis three times a week.Sub-scores of health status, the features related to hemodialysis, duration of hemodialysis treatments and frequency of weekly hemodialysis were similar.However, the hemodialysis access line affects the quality of life.It was found that 64.9% of participants had arterio-venous fistula vascular access lines.According to our research, emotional role function scores of participants with temporary tunneless catheter vascular lines were significantly higher than those with permanent tunneled catheter vascular line.There are a limited number of studies on this topic.Generally, in previous studies, it has been found that social function and general health perception sub-scores of those with arterio-venous fistula vascular access line are higher than those with a temporary or permanent catheter 19,33 .
In our research, 24% of participants had a family member who received dialysis treatment.The emotional role function score of participants who had another member in their families with dialysis treatment was significantly higher than those without any other family member who received treatment.In the literature, to our knowledge, there is no study indicating the quality of life of patients with a family member who received dialysis treatment.However, the result of our study could be interpreted as the presence of a family member who received dialysis treatment having some positive effects in terms of relieving feelings of loneliness, providing motivation, acting together, going to the dialysis center together and being better understood.
The findings showed that 93.8% of participants had no previous transplantation history and 62.9% considered future transplantation.Physical function scores of those with previous transplantation were significantly higher.Similarly, the physical function scores of those who considered transplantation were significantly higher.There are many studies in the literature that are consistent with our findings in the present study.In his study which problems suffered during the process of organ transplantation and the impact of these problems on the quality of life, Özşaker 34 reported that the transplantation process is one of the important methods for renal failure and as a renal replacement treatment (RRT) transplantation increases the quality of life, and patients felt more confident and better 34 .In their study, Tung et al. reported that transplantation positively affects social and physical health and effective social support mechanisms positively affect the transplantation process 35 .Similarly, Kaya et al. stated that the majority of individuals start doing things they could not do before transplantation.Some could start a new job, and some young ones could return to school 36 .
Using research data, when the quality of life scores were calculated out of 100, the average score of the lowest perceived quality of life physical role function was 20.10 and the average general health perception score was 32.16.The average score for the highest mental health was 55.92 and the average score for social functioning was 48.07.When we considered all the research data, we found that the quality of life of participating dialysis patients was generally poor.However, it varied in different degrees according to various factors.
There are some limitations that should be considered in this study.Firstly, the data were collected from patients receiving hemodialysis treatment in a single rural province.The data are limited to the answers given by the patients who accepted to participate in the study to the questions in the demographic information form and the scale.Another limitation was that the religious and spiritual dimensions of life, which are known to have an intense impact on society and affect the quality of life, were not measured.

Conclusions
CRF is a crucial life-threatening public health problem that is seen in almost every age group.It may cause loss of labor force and comorbidity, which leads to dependency on dialysis centers and health personnel.This study conducted in a province in the Eastern region of our country, Turkiye, indicated a poor quality of life.The main reasons are economic insufficiency, inadequate care and poverty.The purpose of dialysis treatment is not only to prolong life span but also to raise the level of quality of life.Adaptation to treatment course varies according to how the individual perceives the situation he/she is in, the communication and cooperation of team members (nurse, doctor, dietician, dialysis technician) with patients, and support from family and loved ones.When evaluating the quality of life, it is essential to bring the health status and variables about hemodialysis to the foreground, not ignore socio-demographic features like age, gender, family structure and educational status, and apply a holistic approach to raise the quality of life, use methods to raise the quality of life, evaluate the patient and disease-related factors in a holistic approach.

Table 1 .
Distribution of participants according to demographic features.

Table 3 .
Comparison of SF-36 Quality of Life Scores according to Gender, Age, Marital Status, Number of Children, Family Type and Educational Status.*Groups with statistically significant differences between them were marked with upper symbol.

Table 4 .
Comparison of SF-36 the quality of life scores according to participants' descriptive features.CRF chronic renal failure.*Groups with statistically significant differences between them were marked with upper symbols.