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Quality of life/spirituality, religion and personal beliefs of adult and elderly chronic kidney patients under hemodialysis 1

OBJECTIVE: to assess the quality of life of chronic kidney patients undergoing hemodialysis, using the WHOQOL-bref and WHOQOL-SRPB. METHOD: a descriptive and cross-sectional study was undertaken at a kidney replacement therapy service in the interior of the state of SP. The 110subjects who complied with the inclusion criteria answered the Subject Characterization Instrument, the WHOQOL-bref and WHOQOL-SRPB. RESULTS: most of the respondents were male (67.27%), with a mean age of 55.65 years, Catholic (55.45%), with unfinished primary education (33.64%) and without formal occupation (79.08%). The WHOQOL-bref domains with the highest and lowest mean score were, respectively, "psychological" (µ=74.20) and "physical" (µ=61.14). The WHOQOL-SRPB domains with the highest and lowest mean score were, respectively, "completeness and integration" (µ=4.00) and "faith" (µ=4.40). CONCLUSIONS: the respondents showed high quality of life scores, specifically in the dimensions related to spirituality, religion and personal beliefs. Losses were evidenced in the physical domain of quality of life, possibly due to the changes resulting from the chronic kidney disease and hemodialysis treatment.


Introduction
Among the different diseases in this current epidemiological scenario with a predominance of chronic non-transmissible diseases, one of the conditions that increasingly stands out is Chronic Kidney Failure (CKF), due to the gradual increase in the prevalence and incidence of this disease all over the world and its high morbidity and mortality, thus representing a great social and economic challenge for public health in the global context (1)(2) .
CKF involves a renal injury and the progressive and irreversible loss of kidney functions (glomerular, tubular and endocrine). In its most advanced phase (called endstage CKF), the kidneys are no longer able to maintain the normality of the patient's internal environment and dialysis treatment is needed (3) .
Terminal CKF and its treatments can influence the patients' biological, psychological, economic and social dimensions and interfere in their Quality of Life (QoL).
In addition, chronic kidney patients tend to have a lower QoL, a characteristic already associated with the growing population of CKF patients (4)(5) .
In this context, scientific studies that mainly focu on the most compromised aspects of the QoL in this patient group are increasingly necessary to guide interventions aimed at improving the level of health in this population (6) .
Religion and spirituality are important for dialysis patients, as they are influential in important aspects of QoL and in coping with the disease (2) . Associations have been demonstrated between greater religiousness and/ or spirituality and a better quality of life (2,(7)(8) . Hence, the assessment of these patients' QoL with regard to spirituality and religion is an essential step to raise awareness on the importance of these factors in this population's life and wellbeing, as well as to promote actions that help the patients in their contact with the disease, its treatments and its harmful aspects in different contexts of daily life, and the WHOQOL-Spirituality, Religion and Personal Beliefs (SRPB) is an effective and innovative tool for that end, as this generic instrument enhances the construct created for the WHOQOL-100 and WHOQOL-bref (9) , created to measure the QoL with regard to spirituality, religion and personal beliefs (7) .
Recently, the Brazilian version of this instrument has been validated, and its study revealed the satisfactory psychometric properties of the WHOQOL-SRPB in Brazilian Portuguese (10) .   WHO's WHOQOL Group (11) developed the WHOQOLbref, which has been validated in Brazil (12) . It includes four domains: physical, psychological, social relations and environment. In this study, the score from 0 to 100 was used and, the higher the score, the better the QoL.

The Mental Health Division of the World Health
Organization (WHO) started developing the WHOQOL-SRPB module in the mid-1990's (9) . In Brazil, the version of the WHOQOL-SRPB was validated in 2011 (10) . The Faith) (10) . The mean final facet and global scores can range from 1 to 5 and, the higher the score, the better the individual's QoL.
It should be highlighted that, when using modules from the WHOQOL-Group instruments, the generic instrument (WHOQOL-100 or WHQOOL-bref) is used in combination (10) . Therefore, in this study, the application of the WHOQOL-bref and WHOQOL-SRPB       Table 3 shows the respondents' mean scores on the WHOQOL-bref. The highest scores were found in the domains "psychological" and "social relations", while the "physical" domain obtained the lowest mean score.

Results
As regards the internal consistency of the WHOQOLbref, the instrument showed satisfactory reliability for

Discussion
In this study, most of the interviewed subjects were adults. In a study involving data from chronic kidney patients under dialysis treatment registered at the Nephrology Unit of the Hospital de Base em São José do Rio Preto (SP), aimed at characterizing the patients; verifying the causes of CKF; identifying the diseases associated with CKF and surveying the treatment type and the patients' current access, the sample included more adult than elderly people (77%) (13) . Nevertheless, a trend exists towards a gradual increase in the number of elderly patients with CKF, as advanced age can be considered an influential factor in the increase in the number of elderly HD patients (14) .
Most of the respondents were male (67.27%).
According to the 2011 Brazilian Dialysis Census (15) , Grande (PR), aimed at studying the initial stage of CKF in this population, showed that the subjects' mean per capita income was also relatively low and corresponded to less than one minimum wage for 75% of the sample (16) .
The number of respondents who reported having a fixed partner was higher than those declared without partners/alone, as well as in the study developed at 12 dialysis services in the city of Belo Horizonte (MG), which also used a sample of chronic kidney patients in HD (6) .
The predominant religion among the participants was Catholicism. Other studies support this result, like the study undertaken at a general philanthropic hospital in a city in the state of Minas Gerais, in which the objective was to identify and clinically validate the defining characteristics proposed for the nursing diagnosis "impaired spirituality", with CKF patients receiving HD, in which the population declared Catholic was 79.2% (17) .
The interviewees' mean length of HD in this research was 46.35 months. In the study undertaken at the Hospital de Base de São José do Rio Preto (SP), aimed at assessing the QoL of people undergoing HD treatment, it was observed that the mean length of treatment in the sample was 28.5 months, ranging between 1 and 108 months (1) .
The mean scores obtained when applying the WHOQOL-bref in the sample of the 110 subjects showed that the "physical" domain was more affected. In the search for research that used the WHOQOL-bref to measure the QoL of CKF patients, several studies were found. Different studies developed with the CKF population found the lowest mean score in the physical domain (8,18) .
The low mean scores in the physical domain reaffirm the harmful aspects of CKF and hemodialysis treatment for the patients' QoL, with regard to their wellbeing and physical health (19) .
The WHOQOL-bref domains with the highest scores in this study were "psychological" (m=74.20; SD=15. 12) and "social relations" (m=73.11; SD=19.11). Similar results were found in different studies published in the Brazilian and international literature involving the CKF population receiving dialysis (8,18) .
Concerning the assessment of the respondents' QoL in this study, using the WHOQOL-SRPB, high mean scores were found, ranging  (20) .
The global internal consistency of the WHOQOL-SRPB applied to the 110 subjects in this study was 0.95, similar to what was found in the validation study of that instrument in the Brazilian context, in which the consistency coefficient was 0.96 (10) , and also similar to the coefficient found in the study about the validation of the WHOQOL-SRPB in French, equal to 0.96 (21) .
In another study that explores the relation between presence of a chronic illness and with the importance granted to the domains. According to the results obtained through the application of the WHOQOL-100, the authors identified that the QoL domain -SRPBobtained a slightly higher mean score than the other domains for the chronic patients, but that this difference was statistically insignificant. The WHOQOL-SRPBi score also revealed that the patients obtained a higher mean score than the healthy individuals, highlighting that they granted more importance to the aspects related to spirituality, religion and personal beliefs (23) .
In the validation study of the French version of the WHOQOL-SRPB, 561 voluntary participants completed the instrument. According to the mean scores obtained, the domains with the highest and lowest mean score were, respectively, "Awe" (μ=3.84) and "Faith" (μ=2.43), while the global domain obtained a mean score of 3.05 (21) . In comparison with the present study,