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Psychosocial factors among end-stage kidney disease patients receiving hemodialysis treatment in Kumasi, Ghana

Background: End-Stage Kidney Disease and its maintenance hemodialysis treatment force patients to make several lifestyle changes to cope with this debilitating illness. These changes often trigger the onset of notable psychological distress and depressive symptoms. Furthermore, these negative psychological experiences can undermine the eff ectiveness of the treatment and consequently worsening the health and quality of life of patients.


Introduction
End-Stage Kidney Disease (ESKD) is the inal stage of chronic kidney disease that is characterized by the complete loss of kidney function persisting over three months [1,23]. Globally the incidence of ESKD is on the increase. For instance, in 2018, ESKD had a prevalence rate of 2204 per million in the U.S. population; in that same year, the number of newly reported ESKD cases were 124,500 [2].
In Africa, ESKD is estimated to affect about 10.4% of some populations [3]. The prevalence of Chronic Kidney Disease (CKD) in sub-Saharan Africa was reported to be 13.9% in a meta-analysis [4]. In Ghana, there seems to be a signi icant rise in chronic kidney disease at various stages, with an estimated prevalence of 13.3% [5]. At end of the year 2017, there were 686 patients with ESKD receiving renal replacement treatment (RRT) giving the RRT rate of 23.56/ per million population (pmp) [5]. One more study reported that the prevalence of CKD was 30% among patients with both diabetes and hypertension in Ghana, making it a signi icant public health issue [6].
In Ghana, hemodialysis (HD) is the main treatment option as there is no national renal transplantation programme [5].
The ESKD as a disease entity, maintenance dialysis treatment as well as its associated demands have a signi icant impact on the patients' physical and emotional wellbeing and interfere with the patients' social roles [7].
The diagnosis of ESKD precipitates many emotions, including fear and anger, despair and hope. Life with kidney failure becomes challenging [9]. Patients' physical health, functional status, personal relationships, social and economic prosperity are greatly affected [8]. These experiences show that the psychosocial environment in which ESKD patient lives might affect the course of the disease and the patients' physical well-being [9].
Depression and anxiety have been reported to be the most common psychological conditions among ESKD patients receiving hemodialysis [8]. Depression in renal patients has been associated with a more negative perception of disease [9], poor adherence to dialysis treatment, increase mortality, suicidality [8,21] , and a decreased Health-Related Quality of Life (HRQOL) [10].
Anxiety has been associated with decreased HRQOL, primarily in the irst few months of HD and in elderly patients 11 . Patients with both depression and anxiety may represent a population at particular risk of high mortality and morbidity. Comorbid depression has been associated with more profound physiological abnormalities and treatment resistance [12]. Therefore, ESKD, which is prevalent in Ghana [5,9], and associated with highly negative psychosocial outcomes in patients treated with HD, needs to be studied using Ghanaian samples to address the negative psychological problems (depression and anxiety). Undesirably, to our best knowledge, these psychosocial variables in most dialysis patients in Ghana are not assessed. Thus, the objective of the current study is to assess the psychological experiences (depression and anxiety) of ESKD patients receiving HD treatment in Kumasi. The study also aimed at exploring how social support is associated with the state of psychological wellbeing of HD patients.

Study design
A cross-sectional study was conducted to assess the psychosocial factors among HD patients in the Kumasi Metropolis. The psychosocial factors assessed were depression, anxiety, and perceived social support of individuals diagnosed with ESKD and receiving HD treatment within the study centers.

Study setting
The study was conducted at the dialysis unit of the Komfo Anokye Teaching Hospital (KATH) and Naghe Dialysis Clinic, both in Kumasi, Ghana. KATH is a 1000-bed capacity tertiary medical institution that receives referrals from eight of the ten regions of the country owing to its strategic location at the con luence of the country's transportation network. Naghe dialysis clinic is also a specialized private dialysis center that attends to patients with ESKD and CKD-related conditions. As at the time of data collection the dialysis unit at KATH had a population of 22 ESKD patients receiving regular HD treatment whiles Naghe Clinic had a total of 10 HD patients.

Sample size
For the current study, researchers used the census sampling method, as the entire population was small. Hence, all patients who met the criterion were approached to participate in the study. Thirty-one patients were eligible for the study and out of that, 30 participants were used for this study as one patient declined participation based on not being interested.

Sampling methods (Inclusion and exclusion criteria)
Purposive sampling was used to select respondents. Speci ically, respondents were recruited based on these criteria: 1) Clinical diagnosis of ESKD (patient's clinical notes were examined to con irmed diagnosis); 2) HD treatment duration not less than 3 months; 3) and aged 18 years and above.

Research instruments
The following pre-existing self-reported scales were adapted, the Hospital Anxiety and Depression Scale (HADS). HADS was used to assessing anxiety and depression among participants while the Multidimensional Scale of Perceived Social Support (MSPSS) was used to assess perceived social support.
Scores on the HADS range from 0 to 21. A score between 0-7 indicates a normal functioning or sub-clinical range; a score of 8-10 indicates a borderline abnormality and a score ranging from 11-21 indicates abnormal (severity of the condition).
A mean score of the MSPSS was calculated from a total scale to indicate the level of perceived social support. Furthermore, in using the scale response descriptors as a guide, means ranging from 1 to 2.9 could be considered low support; those ranging from 3 to 5 could be considered moderate support, and mean scores within 5.1 to 7 could be considered high support.
A pretesting was conducted at the Cape Coast Teaching Hospital to ascertain the reliability and validity of the adapted scales on a Ghanaian population, hence 10 hemodialysis patients from the Cape Coast Teaching Hospital were used. The reliability was tested scale by scale to ascertain the internal consistency of the items. The results indicated a Cronbach's alpha for HADS as (0.71) and MSPSS as (0.89).

Statistical analysis
Statistical Package for the Social Sciences (SPSS) version 20 was used to analyze data. The scales were coded. Serial numbers were given to each scale for easy identi ication. The editing procedure was to check whether respondents had followed directions correctly and answered all questions. Obtained demographics were coded as well. The data was edited after input Categorical variables were analyzed and presented as frequencies and percentages. The continuous variables were presented as means and standard deviations.
The Pearson Correlation Coef icient was used to compute the relationship between depression states, anxiety states, perceived social support, and income levels of participants. The signi icance level for all analyses was set at a p -value less than 0.05, two-tailed.

Ethical approval
Ethical approval was obtained from the Committee on Human Research Publication and Ethics (CHRPE) of KATH/ KNUST (CHRPE/RC/83/16); after which the necessary contact with the head of the two dialysis centers was established. Permission was obtained for the administration of the instrument. Informed consent and a participation lea let, explaining the purpose of the study and assurance of con identiality and anonymity to respondents, preceded the administration of questionnaires.

Demographic data
There were a total of 30 participants, 18 (60%) males, and 12 (40%) females. The oldest participants were in their early sixties and the youngest were in their twenties. The age range distribution is shown in table 1. Most of the respondents 22 (73.3%) were married, a few widowed (3, 10.0%), and some single (2, 6.7%) or separated (2, 6.7%).
The majority of the respondents had been on HD treatment between 3-6 months, whiles some had been on dialysis between 7-12 months. The results also showed that some respondents had hypertension while others were both hypertensive and diabetic. Participants were either retired or working part-time. None was working full time ( Table 1).
The Levels of Psychosocial States (Depression, Anxiety and Perceived Social Support). Table 2 shows the prevalence levels of depression, anxiety, and social support among the study subjects. Findings show that the majority (24, of 30; 80.0%) met the recommended threshold (score ≥ 11) for a possible diagnosis of severe depression on the HADS. The anxiety subscale had 19 (63.3%) out of the 30 respondents being in the normal range on the anxiety scale and 6 (20.0%) respondents meeting the recommended threshold (score ≥ 11) for a diagnosis of severe anxiety. On perceived social support, 16 (53.3%) respondents were moderately satis ied with their social support, while, 8 (26.7) of the respondents perceived higher social support.
These results indicate that the majority of the respondents were severely depressed. However, comparatively fewer were thus anxious. Generally, many respondents were somewhat satis ied with the social support they received (Table 2).
Correlation between the Psychological Factors and Income levels of participants.  The study also sought to ind the relationships among the psychosocial factors -that is, depression, anxiety, and social support. The results showed that there is a statistically signi icant negative or inverse correlation between depression and perceived social support score (r = -0.41; p < 0.05). Persons who reported higher social support were less likely to have a high prevalence of depression; and inversely, those who received less social support were more likely to have a high prevalence of depression.
Similarly, there was a statistically signi icant negative correlation between anxiety levels and perceived social support score (r = -0.59; p < 0.05). These results indicated that higher perceived social support was inversely related to anxiety scores among the patients. Here too, the higher perceived social support, the less anxiety was reported.
Examining the relationship of these to income levels, the results showed a signi icant correlation between income levels and depression (r = -0.41, p < 0.05), indicating that higher income levels were associated with a decreased prevalence of depression among patients undergoing HD in Ghana. However, the relationship of income to anxiety was insigni icant (Table 3).
of depression among HD patients, it should be noted that the present study's prevalence of (80%) for severe depression is among the highest rate so far. The reason for the high prevalence of depression in this sample could be linked to the ESKD as a disease entity and maintenance HD treatment [7,13,14]. It could also be partly linked to the income levels of participants as this perspective is supported by our study reporting a negative correlation between income levels and depression, this assertion is also supported by previous works [19,20]. Several studies have looked into possible social, clinical, and psychological factors associated with depression in ESKD patients. For example, a literature review studying depression in HD patients identi ied several risk factors for developing depression including gender, sleep quality, employment, and inancial status [31].
We, therefore, hold the view that the high cost of the HD treatment in the country coupled with the inding that none of our participants was working full time and some others being laid off because of the ESKD; suggests greater inancial dependency in this sample. Patients on average pay between GH 450-GH 550 cedis per week for dialysis treatment (a total cost for 2 sessions in a week). This amount is usually out of the reach of many patients as most of them are unemployed, retired, or laid off because of the ESKD and its treatment modality. Hence, the inancial burden of patients could be linked to the prevalence of depression in this sample.
In the current study, a few (6, 20.0%) respondents' scores met the criteria for severe anxiety; a inding that is consistent with the Cukor et al., a study in which a 19.0% to 30.0% prevalence of anxiety was reported among dialysis patients [11]. Several other studies report an increased level of anxiety in HD patients, with most of these studies reporting a prevalence rate ranging from 1% to 45.7% [29,32,33].
Several studies have reported on the negative consequences of depression and anxiety on treatment outcomes of ESKD. Studies have shown that HD patients with a diagnosis of depression have a worse treatment outcome such as higher rates of hospitalization, higher rates of dialysis withdrawal and mortiality [25,26], as well as increased usage of the healthcare system [27]. According to Farrokhi, et al, the presence of depressive symptoms is associated with a 50% increase in the risk of mortality [28].
Compared to depression, anxiety has received less attention concerning studying its consequences on clinical outcomes among HD patients. Notwithstanding that, the prevalence of anxiety in patients on HD has been shown to result in a signi icantly lower quality of life (QoL) than patients with no psychopathology and even lower QoL than patients with only a depressive disorder [29,30]. Given the reported prevalence of depression and anxiety in our study, it can be inferred that our participants are at a greater risk of higher rates of hospitalization, higher inpatient days, higher rates of

Discussion
This study assessed psychosocial factors among ESKD patients receiving HD treatment in Kumasi, Ghana. We found that the majority of the respondents met the criteria for a diagnosis of severe depression; corroborating previous studies that have found that HD patients go through physical and psychological turmoil such as depression [13,15,20,22].
Among psychosocial factors assessed in this study, the highest impairment was seen in depression as the study results reported that 80% of the patients had a higher (severe) score on the depression subscale of the hospital anxiety and depression scale (HADS). This indicates that generally, endstage kidney disease patients receiving HD in our study were severely depressed. The results from our study are comparable to a study that used the HADS scale in patients with chronic renal failure [13]. Findings from this study are also consistent with another study that investigated the factors affecting the quality of life of renal failure patients and found a 70% prevalence of depression among dialysis patients using the Beck Depression Inventory (BDI); indings that showed that depression has a signi icant impact on patients' perception of their quality of life [14].
Albeit previous studies have documented a high prevalence dialysis withdrawal, and mortality. Hence, the focus should be on early identi ication and improvements in the negative psychosocial experiences, including depression and anxiety in ESKD patients receiving HD treatment in Ghana.
Findings from this study revealed that there is a negative correlation between perceived social support and depression. Indicating that our study participants who had high social support from friends, family, and signi icant others were less likely to have a high prevalence of depression whiles those with low levels of social support were more likely to have a high prevalence of depression. The inding emphasizes the importance of social support to patients with ESKD for greater satisfaction with life and positive affect [15,16].
Similarly, anxiety was negatively correlated with social support in this study af irming that ESKD patients with more supportive environments are more likely to experience lower levels of anxiety. This too is consistent with previous works [17,18]. These indings suggest that ESKD patients who bene it from good social support resources are likely to display less psychological distress and depressive symptoms. Previous studies have established that there is an association between survival and perceived social support in ESKD patients as high levels of social support have been associated with increased utilization of medical services [15]. According to a study by Mollaoglu, social support and anxiety were signi icant predictors of self-care after controlling for the effect of time on dialysis [24]. Indicating that patients who perceived higher levels of social support and lower levels of anxiety were more likely to have a higher level of self-care in ESKD patients [24].
Given the observed inverse association between depression, anxiety, and perceived social support in the current study, Health facilities should implement a psychosocial education program to help ESKD patients and their families attain a better understanding of how social support (from family, friends, and signi icant others) will go a long way in helping patients achieve better treatment outcome.

Conclusion
End-Stage Kidney Disease is one of the devastating chronic disorders with several public health issues affecting an increasing number of people in Ghana [7]. HD is a lifesustaining treatment for patients with ESKD; however, this treatment modality has been noted to have a detrimental effect on patients' mental status [20]. Progressively, depression is being recognized as a substantial comorbid illness in these patients. Anxiety and impaired HRQOL are also signi icant interrelated psychological conditions [10][11][12][13].
The current study was not without limitations. The subjective nature of self-report scales and the cross-sectional nature of the current study were seen as limitations as the time effects of the study variables were unclear. Notwithstanding, the current study has added to the existing literature on ESKD in Ghana. Given the observed relationship between depression and income levels, HD treatment should be made more affordable to these patients to reduce the prevalence of depressive symptoms. Social support resources for them cannot be overemphasized as it has an impact on patients' prevalence of psychological distress and depressive symptoms [16,17].
Furthermore, an integrated and holistic approach to treatment that incorporates psychological services, such as counseling, should be provided at the dialysis units for patients and their families to adequately prepare them before dialysis treatment commences. An initial systematic assessment of a patient's mental status would aid better treatment planning that facilitates the provision of continuous psychological support.