Int Urol Nephrol (2012) 44:245–253

DOI 10.1007/s11255-011-9975-0

NEPHROLOGY–ORIGINALPAPER

Quality of life and mental health in hemodialysis

and peritoneal dialysis patients: the role of health beliefs
Paraskevi Theofilou

Received: 31 December 2010 / Accepted: 15 April 2011 / Published online: 6 May 2011
Springer Science+Business Media, B.V. 2011

Abstract Conclusions The beliefs that dialysis patients hold

Background and objective Patients’ beliefs regard- about their illness appear to be related to the type of
ing their health are important to understand responses renal replacement therapy. These cognitions are
to chronic disease. The present study aimed to associated with HQoL and with mental health.
determine (i) whether beliefs about health differ
between different renal replacement therapies in end- Keywords Anxiety Depression Health beliefs
stage renal disease (ESRD) patients and (ii) whether Mental health Quality of life Renal disease
these beliefs are associated with health-related qual-
ity of life (HQoL), as well as with mental health.
Methods A sample of 89 ESRD patients, 41 on
hemodialysis (HD) treatment and 48 on peritoneal
dialysis (PD) treatment, completed the World Health Introduction
Organization Quality of Life instrument, the General
Health Questionnaire, the State-Trait Anxiety Inven- End-stage renal disease (ESRD) patients have a high
tory, the Center for Epidemiologic Studies Depres- burden of disease (particularly cardiovascular comor-
sion Scale, and the Multidimensional Health Locus bidities) affecting their quality of life (QoL) and
of Control. dramatically shortening their life expectancy [1–3].
Results Regarding differences in health beliefs Therefore, exploring QoL becomes an essential task
between the two groups, HD patients focused more in the management of this population.
on the dimension of internal health locus of control These patients may be faced with serious stressors
than PD patients. This dimension was associated with related to the illness and its treatment, arising from the
better QoL (P = \0.01) and general health (P = 0.03) chronic nature of ESRD and the intrusiveness of the
in the total sample. On the contrary, the dimension of medical treatment [4–10]. They are often confronted
important others in health locus of control was with limitations in food and fluid intake, with physical
associated with higher depression (P = 0.02). symptoms such as itching and lack of energy, with
psychological stressors such as loss of self-concept and
self-esteem, feelings of uncertainty about the future,
P. Theofilou (&)
feelings of guilt toward family members, and with
Department of Psychology, Panteion University,
Eratous 12, 14568 Athens, Greece e-mail: problems in the social domain [11–14].
theofi@[Link] Recent studies in chronic diseases suggest that
QoL and mental health may be related to patient’s

123
246 Int Urol Nephrol (2012) 44:245–253

cognitive representations of illness and treatment. 1st part: 135 ESRD patients were
When confronted with an illness, people create their recruited in order to investigate
the effect of durat ion of treatment
own models and representations of the illness in on their QoL and mental health.
order to make sense of and respond to the problems
they are faced with [15–20].
Regarding health beliefs, it has recently been
recognized that hemodialysis (HD) patients’ belief
that one’s health is controllable was associated with 2nd part: In order to investigate
differences between HD and PD
less depression [21]. Further, after controlling for treatment modalities, without the
baseline level of depression, baseline internal health possible effect of length of
treatment, 41 HD and 48 PD
locus of control was not a significant predictor of patients were selected from the
depression in ESRD patients at follow-up [22]. total cohort of 135 participants.

In other studies, personal control was significantly

Fig. 1 Sample selection flowchart
and positively related to physical and social func-
tioning, bodily pain, general health perception, and
the physical component score in HD and peritoneal
dialysis (PD) patients [4]. A higher personal control (CAPD/PD). Patients on these two treatment modal-
was also associated with a lower emotional response ities had low comorbidity and were undergoing
and a better understanding of the renal disease [13]. current dialysis for a varied period of time. In this
Finally, it has been indicated that better health- respect, participants could be categorized into four
related quality of life (HQoL) in dialysis patients is distinct groups regarding current treatment: (a) HD
associated with higher control beliefs, lower illness patients who recently commenced treatment (\4
and treatment disruptiveness, lower consequences, years), (b) HD patients on long-term treatment ([4
and less symptoms [23]. years), (c) PD patients who recently commenced
The purpose of this study is to examine health treatment (\4 years), and (d) PD patients on long-
beliefs in ESRD patients and their relation to QoL term treatment ([4 years).
and mental health. We mainly hypothesize that a Next, in order to investigate differences between the
stronger internal health locus of control is associated HD and PD treatment modalities, independently of
with better QoL and mental health, indicating less treatment duration, 41 HD and 48 PD patients were
symptoms of depression and anxiety. selected from the total cohort of 135 participants,
according to specified criteria to form two matched
groups (see Fig. 1 sample selection flowchart).
Selection criteria included patients commencing
Materials and methods dialysis treatment within a 4-year period and ensured
a balanced ratio of men/women participants among
Study design the two groups. Following the selection procedure,
the two groups were tested for significant differences
This study consists of two main parts. The first regarding sociodemographic variables. As seen in
investigates the effect of duration of treatment on QoL Table 1, the groups can be considered equivalent,
and mental health of HD and PD patients. For this with no statistically significant differences between
purpose, a cohort of 135 ESRD patients were recruited them (P [ 0.05).
from dialysis units in three General Hospi-tals located All subjects were informed of their rights to refuse
within the broader area of Athens and consisted of: (a) or discontinue participation in the study, according to
77 patients (57.0%) undergoing in-center hemodialysis the ethical standards of the 1983 Helsinki Declara-
(HD) and (b) 58 patients (43.0%) undergoing tion. Ethical permission for the study was obtained
continuous ambulatory peritoneal dialysis from the scientific committees of the hospitals.

123
Int Urol Nephrol (2012) 44:245–253 247

Table 1 Sociodemographic characteristics of the sample depression. Higher scores indicate a worse gen-
(N = 89) eral health status.
HD N = 41 PD N = 48 P valuea 3) The State-Trait Anxiety Inmentory (STAI 1/STAI
(46.06%) (53.9%) 2) consists of 20 items referring to self-reported
Age (years) NS
state anxiety and 20 items referring to trait
Mean 65.34 (8.37) 64.10 (10.36)
anxiety [28, 29]. State anxiety reflects a ‘‘tran-
(SD) sitory emotional state or condition of the human
Gender NS organism that is characterized by subjective,
Male 21 (51.30%) 23 (47.90%) consciously perceived feelings of tension and
Female 20 (48.70%) 25 (52.10%) apprehension, and heightened autonomic ner-
Total 41 (100.0%) 48 (100.0%)
vous system activity’’; it may fluctuate over time
Marital NS
and can vary in intensity. In contrast, trait
status anxiety denotes ‘‘relatively stable individual
Single 4 (9.75%) 6 (12.50%) differences in anxiety proneness’’ and refers to a
Married 33 (80.48%) 38 (79.20%) general tendency to respond with anxiety to
D/W/R 4 (9.75%) 4 (8.30%) perceived threats in the environment [28].
Total 41 (100.0%) 48 (100.0%)
Higher scores mean that patients are more
anxious.
Education NS
0–9 years 29 (70.73%) 26 (54.16%) 4) The Center for Epidemiologic Studies Depres-
[9 years 12 (29.27%) 22 (45.84%)
sion Scale (CES-D) [30–32] is a 20-item self-
Total 41 (100.0%) 48 (100.0%)
report measure of depression. A higher score
means that the patient is more depressed. A
P [ 0.05; N = 89 value above 18 is required for a subject to be
SD standard deviation, D/W/R divorced/widowed/roommate, classified as depressed [32].
HD Hemodialysis, PD peritoneal dialysis, NS nonsignificant
a 5) The Multidimensional Health Locus of Control
Chi-square test
(MHLC) is a self-report tool measuring a
Measurements patient’s beliefs about control over health out-
comes. Health locus of control is one of the
The measurement tools included: widely used measures of individuals’ health
beliefs and has been designed to determine
1) The World Health Organization Quality of Life whether patients are internalists or externalists.
instrument (WHOQOL–BREF) [24] is a self- The inventory consists of 18 items, which
report generic QoL inventory of 26 items, comprise 4 categories of beliefs: (a) internal
validated for Greek populations [25]. The items locus, (b) chance, (c) doctors, and (d) important
fall into 4 domains: (a) physical health, others. The last three refer to external locus of
(b) psychological well-being, (c) social relation- control [33, 34]. The brief description of the
ships, and (d) environment. Two of the items theory explores the fact that health locus of
provide a facet measuring overall QoL/health. control is a degree to which individuals believe
Higher scores indicate a better QoL. that their health is controlled by internal or
2) The General Health Questionnaire (GHQ-28) is a external factors. Whether a person is external or
widely used self-report measure of general health, internal is based on a series of statements. The
developed by Goldberg in 1978 [26], and vali- statements are scored and summed to find the
dated for Greek populations [27]. It may identify above. Externals refer to belief that one’s
short-term changes in mental health and is often outcome is under the control of powerful others
used as a screening instrument for psychiatric cases (i.e., doctors) or is determined by fate, luck, or
in medical setting and general practice. The 28- chance. Internals refer to the belief that one’s
item version used in this study consists of four sub- outcome is directly the result of one’s behavior
scales: (a) somatic symptoms, (b) anxiety/ [33, 34]. The 4 categories are not mutually
insomnia, (c) social dysfunction, and (d) severe exclusive, and scores may weight in a particular

123
248 Int Urol Nephrol (2012) 44:245–253

direction. Higher scores indicate stronger pres- depression (CES-D), state-trait anxiety (STAI
ence of the specific dimension of beliefs. 1/STAI 2), and internal health locus of control.
A P value of 0.05 or less was considered to
indicate statistical significance.
Statistical methods
All analyses were performed with the Statistical
Kolmogorov–Smirnov tests were performed in order Package for the Social Sciences (SPSS 13.0 for
to check whether the values of the sample would fall Windows).
within a normal distribution. Next, the analyses
performed were aimed to:
Results
a) investigate differences between HD and PD
patients, using two groups comprised of selected
The values of the total cohort were found to pass the
cases from the total cohort of 135 patients,
normality distribution test. With regard to illness
equivalent for length of treatment and sociode-
beliefs, a significant difference was observed in HD
mographic characteristics. Independent sample t-
patients presenting higher scores in the dimension of
test was performed in order to check for
internal health locus of control, compared to PD
significant differences in the variable of health
patients. Both groups presented a similar pattern of
locus of control examined in the study. Further,
illness beliefs, according to which higher values were
stepwise regression analysis was used to assess
identified in the internal and chance dimensions
that the association between internal health
followed by the dimensions of doctors and important
beliefs and renal replacement modality is inde-
others (Table 2). A stepwise regression analysis was
pendent from depressive symptoms. A model
also performed (Table 3). Only internal health beliefs
was constructed using renal replacement modal-
proved to be significantly associated with renal
ity as dependent variable. Independent variables
replacement modality.
included depression (CES-D) and internal health
locus of control. A P value of 0.05 or less was Investigating the relation between the dimensions
of health locus of control and QoL as well as mental
considered to indicate statistical significance.
health in the total sample, internal health locus of
b) investigate the relation between health beliefs and
QoL as well as mental health. Thus, correlation Table 2 LHLC in HD and PD patients
analysis was performed using Pear-son’s rho.
Multiple stepwise regression analysis was also used LHLC HD patients PD patients P valuea
factors (N = 41) (N = 48)
to assess that the association between internal M ± SD M ± SD
health beliefs and overall QoL/ health is
independent from depression. Initially, simple Internal locus 27.36 ± 7.00 23.15 ± 8.35 0.01*
correlations were examined between variables Chance 25.21 ± 8.65 23.22 ± 9.16 0.30
referring to health beliefs, QoL as well as mental Doctors 16.48 ± 2.27 16.80 ± 1.72 0.25
health (depression, state-trait anxiety, and general Important others 13.21 ± 4.56 11.80 ± 4.77 0.25
health) in the total sample of ESRD patients. * P \ 0.05; N = 89
Correlation analysis was also performed in order to M mean, SD standard deviation, MHLC multidimensional
investigate the above relation in the groups of HD health locus of control, HD hemodialysis, PD peritoneal
and PD patients separately. As some of these dialysis
a
variables were not significantly related to overall Chi-square test
QoL/health, they were excluded as predictors from
the final regression analysis. A model was Table 3 Stepwise regression analysis for renal replacement
constructed using overall QoL/health facet as modality
dependent variable. Inde-pendent variables Variable Beta Adjusted R2 P value
included these domains of WHOQOL-BREF,
which were correlated to overall QoL/health, sub- Internal locus -0.30 0.07 0.02*
scales of GHQ-28, * P \ 0.05; N = 89

123
Int Urol Nephrol (2012) 44:245–253 249

GHQ General Health Questionnaire,

Table 5 Multiple stepwise regression analysis for overall
CES-D STAI-1 STAI-2 QoL/health facet in the total sample
Total Depression State Trait
Adjusted R2

-0.23 -0.13
Variable Beta P value

-0.10 0.07

110.0.0.
050.0. -0.10
Psychological health 0.64 0.49 0.00*
score anxiety anxiety

Internal locus 0.26 0.55 0.00

01
* P \ 0.05; N = 89
-0.18 -0.14
0.05 -0.15

28*
-0.08 00

control was associated positively with QoL and more

specifically with the domain of psychological health
160.

(r = 0.35, P = \0.01) and the overall QoL/health facet

(r = 0.48, P = \0.01). Internal health beliefs were also
related negatively to general health, measured by
MHLC Multidimensional Health Locus of Control, QoL Quality of Life, WHOQOL World Health Organization Quality of Life,CES-DCenterforEpidemiologicStudiesDepression,STAI-1Stateanxiety,STAI-

GHQ-28 questionnaire, and more spe-cifically to the

sub-scale of somatic symptoms (r = -0.22, P = 0.03).
On the other hand, the dimension of important others
Correlations between MHLC and QoL, general health, depression as well as state/trait anxiety in the total sampleTable4

appeared to have positive corre-lation with

QoL/health symptoms insomnia dysfunction depression
Severe

depression, measured by CES-D scale (r = 0.28, P =

0.02) (Table 4).
A multiple stepwise regression analysis was also
Anxiety/ Social

performed (Table 5). Only psychological health

proved to be significantly associated with overall
QoL/health facet of our patients as well as internal
-0.17

health beliefs.
13Importantothers-0.19-0.150.-0.01-[Link].0.
0.000312

Further investigation was performed in the two

groups of patients, separately. In HD patients,
Somatic

-0.12

internal health locus of control was associated

positively with QoL, especially with the domains of
48**Internallocus0.[Link]. -0.22* -0.10
0.

physical (r = 0.37, P = 0.01) and psychological health

Environment Overall

(r = 0.48, P = \0.01), as well as the overall

0.
-0.07

QoL/health facet (r = 0.59, P = \0.01). Also, inter-nal

GHQ-28

health beliefs were related negatively to general

-0.00

health and more specifically to the sub-scales of

-0.11

somatic symptoms (r = -0.34, P = 0.02), social

-0.06

dysfunction (r = -0.31, P = 0.04), and severe

-0.07
Physical Psychological Social

depression (r = -0.33, P = 0.03) as well as the total

relations

score of GHQ-28 (r = -0.37, P = 0.01) in HD

-0.20 -0.12
-0.03

patients. Furthermore, we found that internal health

locus of control had negative connection with state
17

anxiety (r = -0.49, P = 0.04) (Table 6).

05Doctors-0.02-0.08-0.12-0.110.
health health
WHOQOL-BREF

12
\*P0.**P 0. N = 8905;01;

A multiple stepwise regression analysis was also

performed in the group of HD patients (Table 7).
12 03
-0.03 -0.12

13

Only psychological health proved to be significantly

associated with overall QoL/health facet.
With regard to PD patients, the results showed a
19 35**

positive relation between the overall QoL/health facet

2Traitanxiety

and the internal health locus of control (r = 0.45, P =

MHLC

Chance

\0.01). However, the dimension of important others

03

appeared to have negative correlation with the

\

123
250 Int Urol Nephrol (2012) 44:245–253

Table 7 Multiple stepwise regression analysis for overall

General Health Questionnaire,

CES-D STAI-1 STAI-2 QoL/health facet in HD patients
Depression State Trait
Adjusted R2

-0.49* -0.45
Variable Beta P value

-0.25 -0.23
0.231013
-0.37 -0.34
Psychological health 0.87 0.74 0.00*
anxiety anxiety

* P \ 0.05; N = 41
0.
-0.21
-0.31

000.
0.

domain of psychological health, measured by WHO-

QOL-BREF (r = -0.31, P = 0.03). This dimension
was also related positively to the GHQ-28 sub-scale
of anxiety/insomnia (r = 0.32, P = 0.02), the total
MHLC Multidimensional Health Locus of Control, QoL Quality of Life, WHOQOL World Health Organization Quality of Life, GHQ

score of GHQ-28 (r = 0.31, P = 0.03) as well as to

depression, measured by CES-D scale (r = 0.41,
P = \0.01) (Table 8).
Total
QoL/health symptoms insomnia dysfunction depression score

A multiple stepwise regression analysis was also

performed in the group of PD patients (Table 9).
Severe
Correlations between MHLC and QoL, general health, depression as well as state/trait anxiety in HD patientsTable6

Only psychological health proved to be significantly

associated with overall QoL/health facet as well as
-0.37*37*48**260659**
00Chance0.-0.16-0.220.-0.160.-0.10-0.030.0.

internal health beliefs.

Anxiety/ Social

-0.03
0.07040503

CES-D Center for Epidemiologic Studies Depression, STAI-1 State anxiety, STAI-2 Trait anxiety
-0.03

Discussion

The present study examined the nature of illness

Somatic

06Importantothers-[Link].0.0.-0.140.
0.
-0.33*

cognitions in ESRD patients on different types of

renal replacement therapy and their associations with
-0.08

QoL and mental health.

Environment Overall

-0.31*

Regarding health beliefs, HD patients indicated a

0.

greater preference to the internal dimension, focusing

GHQ-28

more on their own personal control to regulate their

-0.27

0.

health condition. This may reflect a stronger need of

10

these patients to counterbalance the imposed depen-

-0.05
-0.34*

dence on the dialysis procedure and the restrictive

Physical Psychological Social

dietary regimen by exercising control over their illness.

relations

Further investigation into this hypothesis is necessary.

-0.13
0.

Concerning the relation between the dimensions

00
0.

-0.23

of health locus of control and QoL in the total

sample, it seems that internal health beliefs may help
02
health health
0.
WHOQOL-BREF

\05; 01;*P0.**P0. N = 41

the patients to face their problems related to ESRD

-0.19

and evaluate in a positive way their QoL and the

09
0.

status of general health, showing better psychological

00
0.

health and less somatic symptoms. These results

-0.07
03

correspond to previous findings that internal health

Internal locus

locus of control is associated with better QoL and

06

understand-ing of patients’ illness [13]. On the other

Doctors
MHLC

hand, focusing on important others’ control and

03

00

respon-sibility over one’s condition seems to indicate

\

123
Int Urol Nephrol (2012) 44:245–253 251

Table 9 Multiple stepwise regression analysis for overall

General Health Questionnaire,

STAI-1 STAI-2 QoL/health facet in PD patients
Trait

0.41**1925
Adjusted R2

0. -0.1904
Variable Beta P value

-0.14 -0.05
Depression State

Psychological health 0.56 0.41 0.00*

anxiety anxiety

18-0.10-0.010.
Internal locus 0.29 0.47 0.01

0.
* P \ 0.05; N = 48
CES-D

-0.11
-0.16

0.
depressive mood. ESRD patients are reported in the
relevant literature to present depressive symptom-
atology [35–41].
In further investigation that was performed in the
MHLC Multidimensional Health Locus of Control, QoL Quality of Life, WHOQOL World Health Organization Quality of Life, GHQ

two groups of patients separately, the above conclu-

sions are confirmed. Specifically, in HD patients,
internal health locus of control contributes to a
positive perception of their QoL, indicating better
physical and psychological health as well as overall
Correlations between MHLC and QoL, general health, depression as well as state/trait anxiety in PD patientsTable8

QoL/health. Also, internal health beliefs help HD

patients to evaluate more favorably not only their
0.05002232*272931*

status of general health with less somatic symptoms,

Total

-0.151028072045**

social dysfunction, and severe depression but also

QoL/health symptoms insomnia dysfunction depression score

their mental health showing less state anxiety. In the

-0.2100070520

CES-D Center for Epidemiologic Studies Depression, STAI-1 State anxiety, STAI-2 Trait anxiety
Severe

relevant literature, it has been suggested that personal

control is significantly and positively related to
physical and social functioning and general health
Anxiety/ Social

perception in these patients [4, 42–44].

0.

As far as PD patients are concerned, internal

05Chance-0.08-0.06-0.14-0.270.-[Link].0.
-0.16

-0.24

health locus of control relates to a positive cognition

0.

regarding overall QoL/health. However, the dimen-

-0.02

-0.14

sion of important others leads to a negative evalu-

0.

ation of QoL and mental health, indicating more

Somatic
GHQ-28

depressive symptoms, anxiety, and insomnia.

-0.09

-0.19
0.

Further, it is important to point out that psycho-

logical health seems to play a substantial role in
- 0.13
Environment Overall

-0.21

-0.16

patients’ QoL and more specifically in the favorable

way that HD and PD patients evaluate the level of
0.

0.

their overall QoL and health.

0.

Limitations of the study may include the lack of

0.
0.

-0.25

investigating the effect of clinical factors, such as

0.

adequacy of dialysis, hemoglobin level, dialysis

-0.31*
10
WHOQOL-BREF
Physical Psychological Social

\05; 01;*P0.**P0. N = 48

vintage, presence of diabetes mellitus, or other clinical

0.
relations

parameters on the patients’ perceptions of QoL and

0.
07

Important others -0.23

mental health. There is also a need for future research to

0.
0.

use prospective and longitudinal study designs to

05
0.

examine the interaction of illness and treatment

Internal locus
health health

cognitions and outcomes and how these change over

time, during the course of the illness.
Doctors
MHLC

Another methodological issue is related to the

06

sample representativeness. Studies on the broader

\

123
252 Int Urol Nephrol (2012) 44:245–253

ESRD population and recruiting even larger samples health beliefs in end-stage renal disease (ESRD) patients.
to enable effective multi-group analysis should be Paper presented at the 17th European congress of psychi-
atry, Lisbon, Portugal, 24–28 January 2009
pursued in future research.
7. Theofilou P (2011) The role of sociodemographic factors
Finally, regarding limitations of the study, it is in health-related quality of life of patients with end-stage
important to say that STAI 1/STAI 2, CES-D, and renal disease. Int J Caring Sci 4:40–50
8. Theofilou P (2010) Psychiatric disorders in chronic peri-
MHLC questionnaires are not validated in Greek odical hemodialysis. Vima Asklipiou 9:420–440 (in Greek)
ESRD population, thus not informing about the 9. Theofilou P, Panagiotaki E (2010) Factors affecting
sensitivity and the internal consistency of these quality of life in patients with end-stage renal disease.
measurements. Future studies are needed, using the Nursing 49:174–181 (in Greek)
above methods in patients with ESRD, in order to 10. Theofilou P (2010) Quality of life, mental health and
health beliefs: comparison between haemodialysis and
make generalized conclusions on mental health and peritoneal dialysis patients. Interscientific Health Care
health beliefs of this population. 2:171–176 (in Greek)
Despite its limitations, the present study demon- 11. Cameron S (1996) Kidney failure. Oxford University
Press, New York
strates the importance of understanding the illness
12. Christensen AJ, Ehlers SL (2002) Psychological factors in
and treatment beliefs of patients with ESRD and the end-stage renal disease: an emerging context for behavioral
contribution of these beliefs to HQoL. This suggests medicine research. J Consult Clin Psychol 70:712–724
the interest for investigating whether individually- 13. Covic A, Seica A, Gusbeth-Tatomir P, Gavrilovici O,
based or group-based interventions that are aimed at Goldsmith DJ (2004) Illness representations and quality of
life scores in haemodialysis patients. Nephrol Dial Trans-
specific, inaccurate, individual illness perceptions plant 19:2078–2083
can improve perceived QoL in dialysis patients. 14. Krespi R, Bone M, Ahmad R, Worthington B, Salmon P
(2004) Haemodialysis patients’ beliefs about renal failure
Acknowledgments The author would like to thank the patients and its treatment. Patient Educ Couns 53:189–196
for their participation in the study and acknowledge the 15. Cameron LD, Leventhal H (2003) The self-regulation of
support given by the health professionals and the health and illness behaviour. Routledge, London
administration personnel of the dialysis participating units. 16. Cameron LD, Moss-Morris R (2004) Illness-related cog-
nition and behavior. In: Kaptein A, Weinman J (eds)
Health psychology. Blackwell Publishing and British
Psychological Society, Oxford
References 17. Caress AL, Luker KA, Owens RG (2001) A descriptive
study of meaning of illness in chronic renal disease. J Adv
1. Covic A, Seica A, Mardare N, Gusbeth-Tatomir P (2006) Nurs 33:716–727
A longitudinal study on changes in quality of life and ill- 18. Hagger MS, Orbell S (2003) A meta-analytic review of the
ness representations in long-term hemodialysis patients common-sense model of illness representations. Psychol
with low comorbidity. Dialysis Mædica-J Clin Med 1:12– Health 18:141–184
19 19. Heijmans M, de Ridder D (1998) Assessing illness repre-
2. Covic A, Gusbeth-Tatomir P, Goldsmith DJ (2003) The sentations of chronic illness: explorations of their disease-
challenge of cardiovascular risk factors in end-stage renal specific nature. J Behav Med 21:485–503
disease. J Nephrol 16:476–486 20. Rees G, Fry A, Cull A, Sutton S (2004) Illness perceptions
3. Theofilou P, Ginieri-Coccossis M, Synodinou C (2010) and distress in women at increased risk of breast cancer.
Sociodemographic variables, health beliefs, psychopatho- Psychol Health 19:749–765
logical symptoms: influence factors of quality of life in 21. Christensen AJ, Turner CW, Smith TW, Holman JM,
patients with chronic renal failure. In: Koulierakis G, Gregory MC (1991) Health locus of control and
Pashali A, Rotsika V, Ginieri-Coccossis M (eds) Clinical depression in end-stage renal disease. J Consult Clin
psychology and health psychology-research and practice. Psychol 59:419–424
Papazisi, Athens (in Greek) 22. Cvengros JA, Christensen AJ, Lawton WJ (2005) Health
4. Timmers L, Thong SY M, Dekker WF, Boeschoten WE, locus of control and depression in chronic kidney disease:
Heijmans M, Rijken M, Weinman J, Kaptein AA (2008) a dynamic perspective. J Health Psychol 10:677–686
Illness perceptions in dialysis patients and their association 23. Griva K, Jayasena D, Davenport A, Harrison M, Newman
with quality of life. Psychol Health 23:679–690 PS (2009) Illness and treatment cognitions and health
5. Ginieri-Coccossis M, Theofilou P, Synodinou C, Tomaras related quality of life in end stage renal disease. Br J
V, Soldatos C (2008) Quality of life, mental health and Health Psychol 14:17–34
health beliefs in hemodialysis and peritoneal dialysis 24. WHOQOL Group (2004) The World Health Organiza-
patients: investigating differences in early and later years tion’s WHOQOL-BREF quality of life assessment: psy-
of current treatment. BMC Nephrol 9:1–9 chometric properties and results of the international field
6. Karamanidou C, Theofilou P, Ginieri-Coccossis M, Syn- trial. A report from the WHOQOL Group. Quality of Life
odinou C, Papadimitriou G (2009) Anxiety, depression and Research 13: 299–310

123
Int Urol Nephrol (2012) 44:245–253 253

25. Ginieri-Coccossis M, Triantafillou E, Antonopoulou V, domains of quality of life to overall quality of life for dif-
Tomaras V, Christodoulou GN (2003) Quality of Life ferent chronic diseases. Qual Life Res 13:883–896
Handbook in reference to WHOQOL-100. Medical Publi- 36. Oikonomidou G, Zlatanos D, Vayopoulos H, Hatzidimi-
cations VISA, Athens (in Greek) triou H (2005) Depression in patients with chronic renal
26. Goldberg DQ (1978) Manual of the general health ques- failure. Dialys Living 14:22–32 (in Greek)
tionnaire. NFER-Nelson, Windsor, England 37. Yucedal C, Olmez M, Gezen G, Celik F, Altindag A,
27. Garyfallos G, Karastergiou A, Adamopoulou A, Mout- Yilmaz ME, Kara IH (2003) Depression in dialysis
zoukis C, Alagiozidoy E, Mala O (1991) Greek version of patients. EDTNA ERCA J 29:160–164 (in Greek)
the general health questionnaire: accuracy of translation 38. Oo TN, Roberts TL, Colling AJ (2005) A comparison of
and validity. Acta Psychiatr Scand 84:371–378 peritonitis rates from the United States Renal Data System
28. Spielberger GO (1970) The state-trait anxiety inventory. data-base: CAPD versus continuous cycling peritoneal
Consulting Psychologists Press, California dialysis patients. Am J Kidney Dis 45:372–380
29. Liakos A, Giannitsi S (1984) Reliability and validity of the 39. Theofilou P (2011) Depression and anxiety in patients
greek state-trait anxiety inventory of spielberger. Egepha- with chronic renal failure: the effect of sociodemographic
los 21:71–76 (in Greek) characteristics. International Journal of Nephrology (in
30. Radloff LS (1977) The CES-D scale: a self-report press)
depression scale for research in the general population. 40. Theofilou P (2011) Quality of life in patients undergoing
Appl Psychol Meas 1:385–401 haemodialysis or peritoneal dialysis treatment. Journal of
31. Hann D, Winter K, Jacobsen P (1999) Measurement of Clinical Medicine Research (in press)
depressive symptoms in cancer patients: evaluation of the 41. Morales-Jaimes R, Salazar-Martinez E, Flores-Villegas FJ
center for epidemiological studies depression scale (CES- (2008) The role of depression in the quality of life among
D). J Psychosom Res 46:437–443 patients undergoing renal substitutive therapy. Gac Med
32. Hedayati S, Bosworth H, Kuchibhatla M, Kimmel P, Mex 144:91–98
Szczech L (2006) The predictive value of self-report 42. Wiebe SJ, Christensen AJ (1997) Health beliefs, person-
scales compared with physician diagnosis of depression in ality, and adherence in hemodialysis patients: an interac-
hae-modialysis patients. Kidney Int 69:1662–1668 tional perspective. Ann Behav Med 19:30–35
33. Wallston BS, Wallston KA (1976) The development and 43. Bremer AB (1995) Absence of control over health and the
validation of the health related locus of control (HLC) psychological adjustment to end-stage renal disease. Ann
scale. J Consult Clin Psychol 44:580–585 Behav Med 17:227–233
34. Wallston BS, Wallston KA, DeVellis R (1978) Develop- 44. Gencoz T, Astan G (2006) Social support, locus of
ment of the multidimensional health locus of control control, and depressive symptoms in haemodialysis
(MHLC) scale. Health Educ Monogr 6:160–170 patients. Scand J Psychol 47:203–208
35. Arnold R, Ranchor AV, Sanderman R, Kempen GIJM, Or-mel
J, Suurmeijer TPBM (2004) The relative contribution of

123