International Journal of Advancements in Research & Technology, Volume 6, Issue 4, April-2017 36

ISSN 2278-7763

Stress and Coping Mechanisms among Hemodialysis Patients in

the Gulf and Neighboring Countries: A Systematic Review
Jeffrey Navarro Rojas1
Sur Nursing Institute, Ministry of Health, Sultanate of Oman
Email: [email protected]

ABSTRACT
Chronic kidney disease is a major health problem due to the significant financial burden for the healthcare system and likewise
for the patient who needs the treatment. The patient’s whole life situation is turned upside down with chronic kidney disease
when they are confronted with the forced change to start treatment with hemodialysis. Patients undergoing hemodialysis re-
quire direct and continuous care. Identifying the stress and coping mechanisms used by the hemodialysis patients could make
other people understand what these daily stressors mean to the patients and how they impact the daily lives of patients on
hemodialysis are important to healthcare professionals who provide direct care for patients on hemodialysis. Thus, this study
will add to existing nursing science knowledge of the person as a focal point of health care development. A literature review was
conducted through sources of data base available in the Medline/Pub Med, Google Scholar, Science Direct, and EBSCO Academ-
ic Search Complete for studies published in Gulf countries. Thirteen studies were found to be related to the domains of hemo-
dialysis stress and coping mechanisms in the GCC and neighboring countries. Almost 42 percent of the published studies (four
studies) were from India, three from Iran, and one each from Turkey, Jordan, Saudi Arabia and Egypt. Although, stress and cop-
ing mechanisms among hemodialysis patients in GCC and neighboring countries are affected by several factors. Thus, it necessi-

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tates the need for identifying these stressors and how they hemodialysis patients cope. Relevant institutions should try to raise
society’s awareness of hemodialysis treatment and associated stressors, and educate about the importance of family and health
professionals support. Additionally, there is a need for nurses and other health providers to intervene in assessing and educat-
ing patients and their families on hemodialysis. The regular psychiatric assessment and counselling 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.

Keywords : Hemodialysis, Chronic Kidney Disease, Stress, Stressors, Coping Mechanisms, Healthcare

1 INTRODUCTION

E nd stage renal disease (ESRD) is a chronic and life-

threatening illness and a worldwide public health prob-
lem. It implies that the kidneys are permanently damaged
stressed by Mo, K.W. [3].
Since stress is a transaction between people and environment
in which the critical mediating variable is people‘s perception
and the person can no longer survive independently without
of a demand and of their ability to cope with it according to
renal replacement therapy. Hemodialysis remains the most
Lazarus, R.S & Folkman, S. [4]., people particularly those un-
common form of treatment for ESRD. Hemodialysis patients
are subjected to multiple psychosocial and physiological stres- dergoing haemodialysis use various strategies to cope with the
sors and may be threatened with many potential losses and stressors related to their disease and the treatment procedures
lifestyle changes [1], [2]. [5], [6].
Individuals undergoing long-term hemodialysis have been Research evidence on stress and coping mechanisms among
found to be subjected to multiple physiological and psychoso- chronic kidney disease/end stage renal disease patients in the
cial stressors and experience personal losses and lifestyle Sultanate of Oman and other Gulf Countries is very few. Expe-
changes. Stress is a common component of everyday emotion- rience of stress is a subjective phenomenon. Hence, there is a
al life and it consists of a number of emotional responses. Dif- need to conduct a systematic review of studies on these areas
ferent level of stress are optimal for different people and learn- in order to gain real insight about factors that cause stress
ing how much stress a person could handle is essential for among hemodialysis patients.
recognizing its effect on the person’s mental, physical, and
emotional well-being. It involves both physical and psycholog-
ical factors. It has direct effects on the body, but how stresses 2 OBJECTIVE OF THE STUDY
people depends on factors such as how people perceive the To do a systematic review of literatures on stress and coping
stressful event, their tolerance for stress, and their personal mechanisms among hemodialysis patients in the GCC and
beliefs about the resources they have to cope with stressors as neighboring countries.
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International Journal of Advancements in Research & Technology, Volume 6, Issue 4, April-2017 37
ISSN 2278-7763
in-patients among hospitals supervised by Medical Sciences
University of Jiroft in 2013. The findings revealed that the psy-
chosocial stressors were reported more bothering than physi-
3 METHODS
ologic stressors and patients experienced them more. The most
A literature review was conducted through online sources of frequent experienced physiological stressors included fatigue,
data base available in the Medline or PubMed, Google Scholar, limitations of fluids, limitations of food and arterial and ven-
Science Direct, and EBSCO Academic Search Complete for ous stick and the most frequent psychosocial stressors in-
published studies in Gulf Countries and nearby countries. cluded limits on the time and place for vacation, boredom,
Search terms used singly or in combination included: renal sleep disturbances and interference with job. Optimistic cop-
dialysis unit, stress, coping mechanisms, and hemodialysis ing mechanism was the most common coping strategies used
patients. Criteria for inclusion were 1) the study was done by the patients. There was statistically significant relationship
among any of the Gulf countries such as Kuwait, Bahrain, between the percentage of experienced stressors in hemodia-
Oman, Qatar, Saudi Arabia, United Arab Emirates including lysis patients and their age [9].
Jordan, Iran, Iraq, Turkey, India and Egypt; 2) related to any of A similar study was conducted in India by Maria Juliana, J. &
the stress and coping mechanism components or domains. No Arjunan, P. [10] which assessed the level of stress and coping
specific range for year of publication was specified, so as to among Indian patients subjected to hemodialysis at Dialysis
retrieve maximum number of studies. Thirteen studies were unit through cross-sectional descriptive research design. Sixty
found to be related to the topic were able to be retrieved from patients were selected using convenience sampling from the
the web search. But one study was found to be repeating the dialysis unit of a tertiary care hospital, South India. Thirty-
information. Thus, there were twelve studies which were final- nine (39) out of the sixty patients were having mild stress and
ly considered for the literature review. twelve (12) of them were having moderate stress. The study
also revealed that 38 of the participants never practiced coping
4 RESULTS whereas 22 of them had practiced sometimes coping. Negative
correlation between the level of stress and coping among the
A systematic review on the epidemiology of end-stage renal patients subjected to dialysis insist on intervention to over-

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disease in the countries of the Gulf Cooperation Council come the stress thereby coping with the present condition.
(GCC) which consist of Saudi Arabia, the United Arab Emi- Stress in human life is often equated with tension, anxiety,
rates, Kuwait, Qatar, Bahrain, and Oman using mixed me- worry and pressure. Chronic renal failure is threatened with
thods. many potential losses and changes in lifestyle, but as the dis-
A study was conducted by Cinar, S., Barlas, G.U., & Alpar, ease progresses, the patient physically may not be able to cope
S.E., [7] whose aim was to determine relationships among up, patients receiving hemodialysis use various strategies to
treatment-related stressors and coping strategies of chronic cope with the stressors related to their disease and the treat-
hemodialysis patients among 224 participants. Data was col- ment procedures. A descriptive cross sectional study design
lected through the use of Hemodialysis Stressors Scale and was used to assess the level of stress and coping strategies
Carver Coping Scale and analyzed by using the linear multiple used by patients among patients undergoing hemodialysis
regression analysis. Results show that the most frequent stres- and to determine the relationship between these stressors and
sors reported were the following: limitation of vacation the coping strategies used by thirty (30) patients undergoing
(80.4%), followed by fatigue (79.9%) and uncertainty about hemodialysis. The results revealed that 97% of the patients
future (79.0%). The most frequently used coping strategies undergoing hemodialysis experienced severe stress where half
were turning to religion, active coping and suppression of of them always adopt emotion focused and problem orienta-
competing activities. Moreover, physical treatment-related tion as their coping strategies while 90% of the patients some-
stressors were significantly related to behavioral disengage- times used avoidance oriented coping strategy, while the oth-
ment. This shows that the Turkish view the belief as the basic ers 56% sometime use the coping strategy of seeking support
and most important aspect of human life so the belief of affects and isolated thought [11].
of coping in this country are different from the Western World. Parvan, K., et at. [12] conducted a study on the coping me-
A qualitative study was carried out on which examined the thods to stress among patients on hemodialysis (HD) and peri-
lived experiences of Jordanian patients with chronic kidney toneal dialysis (PD) at the Imam Reza Educational-Medical
disease who received hemodialysis [8].Seven common themes Hospital, Tabriz, West Azarbaijan, Iran. The findings disclosed
emerged after transcription and analysis and these are: life- that mean score of frequency of use of the coping strategy as
style change, time wasted, symptom-related suffering, marital “sometimes used” for the HD patients was 70.94 ± 18.91 and
and family role disruption, religious commitment disruption, also for PD patients as “seldom used” was 58.70 ± 12.66. The
motivators to alleviate stressors, and experience of healthcare mean score of helpfulness of coping strategies in the HD
providers’ support. Findings likewise revealed areas where group was 49.57 ± 19.42 as “slightly helpful”, whereas in the
nurses and other healthcare providers can improve care for PD group it was 37.21 ± 14.38 as “slightly helpful” Further-
this patient population and for patients with other chronic more, both groups used the emotion-oriented coping styles
illnesses. more frequently than the problem-oriented methods. HD pa-
A descriptive correlational study which utilized Hemodialysis tients used coping methods more frequently than the PD pa-
Stressors Scale (HSS) and Jalowiec Coping Scale (JCS) investi- tients. The majority of patients used emotion-oriented coping
gated the stressors and coping strategies of 70 hemodialysis strategies to deal with stress factors. Use of educational, coun-

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International Journal of Advancements in Research & Technology, Volume 6, Issue 4, April-2017 38
ISSN 2278-7763
selling and supportive programs to assist in coping techniques married, 46.7% (28) of them had completed secondary & high-
can facilitate the coping process with stress factors in dialysis er secondary education, 55% (33) of them were unemployed ,
patients. 60% (36) of them had an income less than 5000 Rupees per
In Saudi Arabia, a descriptive study was conducted among month, 83.3 % (50) of the subjects were Hindus, 57% (37) were
fifty (50) patients with end stage renal disease who were sche- undergoing dialysis for a duration of 0-12 months. There is
duled for hemodialysis to determine the prevalence of psy- positive correlation between Quality of life and Coping strate-
chosocial problems in patients with end‐stage renal disease gy. Study findings also revealed that there is significant asso-
and to assess the prevalence of depression in patients with ciation between the Quality of life and religion.
end‐stage renal disease. The result of the study indicated that Furthermore, a cross sectional study was carried out among 50
hemodialysis severely interferes with social activities of pa- patients with end stage renal disease, who were on chronic
tients & depression is a common psychological problem peritoneal dialysis (CPD = 25) and chronic hemodialysis
among the Saudi patients with ends stage renal disease [13]. (CHD=25), was done for level of stress and stress coping abili-
The individual maintained on hemodialysis is facing multiple ty by Kumar, T.R.U., Amalraj, A., Soundarajan, P., & Abraham,
and potentially overwhelming stressors which impact the level G. [17]. The results showed that the overall mean stress score
of social, psychological, and physical functioning. The patients in the CHD patients was higher (78.3%) than in CPD patients
use various coping strategies to cope with the stressors related (43.3% p<0.001). Coping ability score for CHD patients was
to their disease and hemodialysis treatment. Bukhary, F.E.S., 51.9% as compared to CPD patients (60.9% p<0.001).
Sayied, N.E., Abo -El-Magd, M.H., & Saber, E.H. [14] con-
ducted a study in order to assess the psychological stress fac-
ing the hemodialysis patients, identify the coping strategies
used by these patients and investigate relationship between
5 DISCUSSIONS
these stressors and the coping strategies used by the 250 pa- Chronic kidney disease does not usually cause symptoms un-
tients at the El-Minia University hospital at Dialysis Unit. The til it reaches an advanced stage. During the progression of the
main results yielded by the study proved that 36% of patients disease, the patients experiences some of the common symp-
had moderate level of stress while 14% of them suffered from toms like lack of energy, difficulty concentrating, poor appe-

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severe level of stress. As regards with coping; 36% of the pa- tite, insomnia, muscle cramping, edema, dry skin, increased
tients with age group > 40 years used problem- focused coping urinary frequency, bruising, shortness of breath, and bone
while nearly half 49.6% of males and patients residing in rural pain.
areas used emotion focused coping. The study recommended Considering the increasing rate of hemodialysis patients, dif-
that programs should be planned to educate nursing staff ferent results of previous studies, human’s constant interaction
about stressors related to hemodialysis treatment and coping with the environmental changes and living in today’s modern
strategies with these stressors, in order to encourage patients world, people are exposed to a barrage of constant changes
to use more adaptive problem oriented coping methods. and stressors.
Jadhav, S.T., & Lee, P. [15] conducted a study using a pheno- Dialysis patients need to deal and cope with various aspects of
menological approach to gain insight into the lived experience their disease. Identifying the adaptation methods provides
of stressors experienced by patients’ on hemodialysis treat- valuable information for planning specific treatment and med-
ment. Content analysis was used to analyze the data. Three ical care delivery and improving the performance of medical
main themes emerged namely: physical stressors, psychologi- teams.
cal stressors and socio-economic stressors. Pain, tiredness and Various treatments such as hemodialysis prolong the life of
loss of appetite were the predominant physical stressors re- chronic renal failure disease patients who must tolerate many
ported by participants. Shock and depression on diagnosis physical, emotional, social and economic difficulties. There-
and initiation of dialysis, difficulty adhering to prescribed the- fore, social support is considered as a vital area of investiga-
rapeutic regimen, feeling of being burden on family, fear of tion for such patients.
complications and uncertainty about life were the psychologi- These changes in chronic renal failure patients comparing to
cal stressors reported by participants. A range of socioeconom- healthy individuals are more and different. The type of coping
ic stressors were reported by the participants that included: strategies used by the people depends on several factors in-
loss of employment, financial problems, loss of ability to per- cluding personal experience, social support systems, personal
form activities of daily living and limited social life. beliefs, available resources and genetic background.
A correlational study on quality of life and coping strategy Hemodialysis severely interferes with social activities of pa-
among dialysis patients in selected Hospital at Mangalore was tients & depression is a common psychological problem
carried out by among the Saudi patients with ends stage renal disease.
Raju, R. & Latha, S. [16]. Sixty dialysis patients participated in Recent studies have used different methods to gain insight
the study who were purposively selected to answer the ques- about the experiences of patients living on dialysis. In various
tionnaires on quality of life and coping strategy. The findings ways, these studies have pointed out that dialysis treatment
of the study showed that majority of the dialysis patients imposes many challenges and difficulties for patients and their
68.3% (41) had average quality of life. Highest percentage families, who often require new and different ways of coping.
81.7% (49) had satisfactory coping. 31.7 % (19) of dialysis pa- Lifestyle is markedly impacted by the complex therapy, and
tients were in the age group of 61-70 yrs, majority of the dialy- such experiences require patients to adapt to a new way of
sis patients were males 68.3% (41) , 85% of the subjects were living.

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International Journal of Advancements in Research & Technology, Volume 6, Issue 4, April-2017 39
ISSN 2278-7763
The literature emphasizes the prevalence of fatigue is always port. Additionally, this study supports the need for nurses to
encountered by in patients on long-term dialysis therapy. intervene in assessing and educating patients on hemodialysis.
Findings several investigations reported that fatigue typically Considering the importance of understanding all aspects of
reported post and during dialysis interfered with daily activi- stress factors and coping strategies, regular psychiatric as-
ties and mobility. Moreover, several qualitative and quantita- sessment and counselling could facilitate the coping process of
tive studies have examined hemodialysis stressors. Studies dialysis patients with the stress factors and lead to improve-
have described how treatments impact changes in the patients’ ment in the quality of life as well as promoting physical and
lifestyles such as limited time and freedom, disruptions in mental health of these patients.
their routine (family, marital and work), sleep disturbances, Home dialysis treatment, including peritoneal dialysis, is
boredom, fatigue, limitations of fluid and food intake, and widely used now in the United States and other western coun-
uncertainty for the future. tries. It is proven to be a safe and effective alternative to he-
Studies also revealed that HD patients used emotion-oriented modialysis. Thus, it is recommended that administrators and
coping strategies to deal with the stressors they encountered. policy makers introduce home dialysis to HD patients with
Although many of the emotion-oriented coping strategies CKD when kidney transplant is not feasible or while they are
were identified as helpful coping strategies by the patients, waiting for transplantation.
because the problem-oriented coping strategies are more diffi- HD patients in this study brought up concerns about unem-
cult to respond, these methods were not adequately applied, ployment, reducing hours of work, and quitting work after
which could be due to lack of knowledge among the patients. starting hemodialysis. Thus, this concern needs social support
Psychological stressors were also reported in several studies and the attention of the policy makers because previous stu-
which have reported depression, helplessness, uncertainty dies of employment have often been used as coping strategy.
about prognosis in hemodialysis patients as stressors. The literature review for this study identified no previous re-
search on stress and coping mechanism of Omani patients
who were receiving hemodialysis. Future research is recom-
mended, therefore, to include a more diverse sample that re-
6 CONCLUSIONS flects the Omani population.

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This study has identified stressors experienced by chronic
kidney disease patients on initiation of hemodialysis in Indian ACKNOWLEDGMENT
context. Study’s findings illustrate physical, psychological and The author wish to thank the researcher’s Adviser Associate
socioeconomic stressors experienced by patients. These find-
Professor Dr. Zabidah Binti Putit, Deputy Dean, Faculty of
ings can be utilized to design a pre-hemodialysis preparatory
Medicine and Health Sciences and co-adviser Dr. Dr Sidiah
program which can be implemented for stage-4 chronic kid-
ney disease patients to prepare them for hemodialysis. John Siop, Department of Nursing, Faculty of Medicine and
There are very few studies in the GCC which explored the Health Sciences, Universiti Malaysia Sarawak (UNIMAS).
stresses and coping strategies of individuals experiencing he-
modialysis. Although results of this systematic review cannot
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