Demographic factors affecting quality of life of hemodialysis patients – Lahore, Pakistan

Objective: The objective of the study was to determine the demographic factors affecting Quality Of Life (QOL) of hemodialysis (HD) patients. Methods: This observational study was conducted at Shalamar Hospital, Lahore. Patients of End Stage Renal Disease (ESRD) and on maintenance HD for more than three months were included during the period March to June 2012. Patient of ESRD not on dialysis and Acute Renal Failure were excluded. One hundred and twenty five patients who fulfilled the criteria were included. Demographic data containing age, sex, residence, socio economic status, education, mode of traveling for dialysis, total time consumed in dialysis were collected by the investigators. QOL index was measured using 26 items, WHO QOL BREF. Results: There were 89(71.2%) male and 36(28.8%) female patients. Environmental domain score was highest (p=0.000) than all other domains in HD Patients. In overall analysis age, marital status and total time consumed in getting HD effect QOL significantly (p=<0.05). In domain wise analysis, male has better QOL in social relationship domain than female. Age has negative relationship with physical health and psychological health domain. QOL of unmarried and literate patients is significantly better (p=<0.05) in physical health domain. Employed patients have better QOL in physical, psychological and social relationship domain (p=<0.05) than unemployed patients. Patients of residence of rural areas have better QOL in physical and environment domain. Financial status of HD patients affect QOL in social domain. Distance covered to reach hospital effect QOL in psychological domain (p=<0.05). Patients traveling in private transport have better QOL in environmental domain (p=<0.05). Total time consumed in getting HD effect social relation in QOL (p=<0.05). According to linear regression model, marital status is positive predictor and unemployment is negative predictor of QOL in physical health domain. Age is negative predictor of QOL in psychological domain, monthly income is positive predictor of QOL in domain. Unemployment is positive predictor of QOL in social relation domain. Monthly income and place of residence is positive predictor of QOL in environment domain. Conclusion: Gender, age, marital status, unemployment, residence of rural area, economical status, distance covered to reach hospital, mode of transport, total time consumed in getting HD, effect QOL in HD patient. Education level is a positive factor for improving QOL of HD patients.

and social domains of health that are influenced by a person's experience, beliefs, expectations, and perceptions. 2 Studies have documented that ESRD patients receiving dialysis treatment have a lower quality of life than the people in the general population. 3 Various studies have shown that level of hemoglobin, socioeconomic status, literacy, dialysis program, ethnic groups, sex, mobility, comorbidities (e.g., diabetes), malnutrition, depression 4 and unsuccessful previous renal transplant affect QOL of dialysis patients. 5 Type of renal replacement therapy also affects QOL in these patients. 6 In Pakistan, there is late referral to nephrologist, 7 inadequate dialysis, 8 high rate of depression, 9 malnutrition & anemia, 10 which affect QOL of these patients. In Pakistan, nephrology services are not up to mark due to limited numbers of nephrologists (eighty for population of 163million) 11 and only 40% of the patients have an access to dialysis services. 12 There is deficiency of the trained personals leading to poor quality of dialysis services. There is very limited data in this aspect in our dialysis patients, so this multicentric study was conducted to assess the QOL of HD patients and demographic factors affecting it.

METHODS
This observational study was conducted at Shalamar Hospital, Lahore. Patient of ESRD, on maintenance HD treatment for more than months from three HD centres (Shalimar Hospital n 1 =48, Mayo Hospital n 2 =56 and Doctors Hospital & Medical Center n 3 =21) of Lahore, were included as study subjects who were able to understand, speak/read the local language. Patients of ESRD, on HD for less than three months duration and acute renal failure were excluded from the study. Demographic data was collected using predesigned questionnaire. QOL index was measured using 26 items WHO, QOL BREF (Urdu version Khan MN et al). 13 The WHO QOL BREF Contains 26 questions relating to physical health, psychological, social and environmental status of patients. Question 1 asks about individuals overall perception of QOL and Question 2 is about overall perception of health. Remaining 24 questions are divided in to four domains. Out of the four domains one is physical health and other are psychological, social and environmental domains. All domains have different raw score ranges, for uniformity all raw scores were transformed to 4 -20 range according to WHO guidelines higher scores show a better QOL. All four domains were taken as dependent variables and other demographic factors were taken as independent variables.
Data analysis was carried out using SPSS V-17. Descriptive analysis was expressed in the form of percentages for qualitative variable and ± SD used for quantitative variables. Pearson correlation coefficient was used to calculate the relationship between demographic factors and QOL index. Multiple Linear Regression model was used to assess the significant demographic factors as predictor of QOL. Backward elimination method was used to determine the strongest predictors for each domain. One way ANOVA was used to compare mean QOL of different domains. A P-value < 0.05 was considered as statistical significant.

DISCUSSION
ESRD is a chronic disease which causes a high level of hindrance in different aspects of the patient's live, leading to poor QOL. Patients with low HRQOL pull out from HD treatment more commonly. 14 In domain wise analysis of HD patients, there was highest score in environment domain and lowest in physical domain. Similar pattern was observed by Salim K et al. 15 The reason for worst score in physical domain in HD patients is dependence on medical support, strict treatment regime of twice or thrice weekly HD, stat of pain and misery all the times, disturbed sleep and immobility which affect their QOL. These patients have to face many adversities e.g. specific dietary regimen, changes in their body image, dependence on machines which increases anxiety and affect QOL. Other factors are late referral to nephrologist, use of primary access catheter for dialysis and inadequate dialysis which affect QOL according to international literature.
Gender affects QOL in general population and HD patients as well. 15,16 Females have poor QOL as compared to male patients. In this study, males have better QOL in social relationship domain as compared to females. The reason of better QOL in males is that male have better social relationships (strong relation and sexual activation) and support than females. These patients have more chances of outing and meeting friends which give them encouragement to face challenges of life. Similar observation was made by Santos PR et al. 16 and Salim K et al. 16 Age is one of the important predictor of QOL of HD patients. 17 According to Liu WJ et al, 18 age more than forty years was a significant risk factor of QOL of HD patients. In this study, Age have negative relationship with physical and psychological health domain. As age increases QOL impairs. But it is different as compared to other study by Khaled Abdel-Kader et al. 19 These findings are consistent with the longitudinal HRQOL data in the HD (HEMO) Study, and the North Thames Study findings 20 suggest that targeting future interventions at younger patients with CKD may have a larger impact on improving HRQOL. Marital status affects QOL. The major reason for this is that  25 , there were only 11(8%) patients who were employed and having job, amongst them employment was a better predictor of QOL of HD patients. Employed patients can perform their jobs, have better body image, appearance and self esteem which improves their QOL than unemployed. 25,26 Financial status effect QOL of HD patients. According to a report by Nadia Ayub and Zahid Iqbal, income has a positive influence on life satisfaction. 26 Patients with better income level have no financial stress in getting a dialysis than in patient with lower income because they have good means of transport in case of medical emergency, better living, noise & pollution free environment and social activities which improve their QOL. Patients with good income support have more chances of availing opportunities for recreation and leisure activities which give them feeling of healthy life and improved QOL. Similar pattern is also observed by Seica A et al. 27 According to him, lower socioeconomic status affect QOL in HD patients. Place of residence does not affect QOL in overall analysis but in domain wise analysis patients of rural areas in physical health and environment domain has better QOL as compared to patient living in Urban areas. Although there is improvement in living in urban areas and facilities are more as compared to rural areas but still QOL is better in rural areas. In urban areas, there is burden of traffic on the roads which hinders mobility. In urban areas, life is close to nature, environment is pollution free which improves QOL.
Total time consumed in getting HD effects QOL significantly in social relationship domain than other domains. Actually patients with good social relations were getting support in the form of private transport which helped them in getting HD timely. Moist LM et al, 28 reported similar results. According to him, longer travel time was associated with lower QOL. Government of Pakistan has provided dialysis services at the doorstep of ESRD patients in THQ's and DHQ's hospitals.
Mode of transport effect QOL in environment domain than all other domains. Patients with private transport were having better QOL than public and other transports. Private transport provide them freedom for movement, physical safety and less exposure to physical environment like pollution, noise, traffic, climate and clumsy environment. In public transport they have to wait a lot at bus stops and they spent more time in getting HD. Distance covered to reach hospital effect QOL. Patients who were coming from distance more than 5km their QOL was impaired in psychological domain than other domains. Patients who were coming for more distances were having more worries in getting HD and they have to travel a lot in getting HD which increase the time. As already discussed, time consumed in getting HD effect QOL, perhaps underlying factor is distance covered to reach hospital and private transport.

Limitation of the study:
1. Sample size is small in this study and need to enhance the number of the patients. 2. Patients from other major cities may also be added. 3. There is need to add clinical parameters like hemoglobin, hyperparathyroidism and adequacy of dialysis which also affects QOL of dialysis patients.
4. There is need to conduct prospective study to compare the QOL of the patients.

CONCLUSION
Different factors like gender, age, marital status, unemployment, socioeconomic status, residence of rural area, distance covered to reach hospital, mode of transport, total time consumed in getting HD affect QOL of HD patient. Education level is a positive factor for improving QOL of HD patients.