Determination of body image perception and life satisfaction in patients undergoing hemodialysis

Objective: This descriptive study was conducted in order to determine body image perception and life satisfaction of individuals undergoing hemodialysis treatment. Material and methods: The population of the study consisted of individuals who were treated in hemodialysis units in the city center of Kırşehir. Patients. The study was conducted with 135 patients. Questionnaire, multidimensional body-self relations questionnaire, and satisfaction with life scale were used as data collection tool. Results: According to study results, total mean scores of MBSRQ were signiﬁ cantly low in individuals who were older than 65, illiterate, had an extended family, were unemployed, had low income, suﬀ ered from disease and underwent hemodialysis treatment for 10 years and longer, had arteriovenous ﬁ stula in vascular insertion site, had body mass index within the class of morbid obese, and had no planned transplantation. SWLS mean scores of individuals, who were in the age group of


Introduction
Individuals undergoing hemodialysis treatment have several losses in every aspects due to their disease and continuously encounter with stressors from onset of disease.It is reported that mental disorder is frequently observed in patients in luenced by these severe physical and psycho-social stressors and psychological effects of disorders in this group of patients should not be ignored [1].One of these problems is that body image is disturbed.
Body image is an important issue in patients cured with hemodialysis [2].According to Leung's de inition "Body image is the mental picture that people have of their own body and bodily functions including associated external and internal sensations" [3].As a chronic disease, ESRD changes the patients' body and affects their body image negatively [4].In 2013, the results of a cross-sectional study in the UK by Leonard showed that body-image disturbance is higher in hemodialysis patients in compared to general population [5].
Physical changes such as dependence to hemodialysis process at certain intervals because of total or partial function loss of kidney, existence of istula, shunt on arm or catheter in the body in order to undergo hemodialysis, uremia related color change on the skin, pallor caused by anemia occurring as a result of suppression of bone marrow due to uremia, and bodily changes such as weight gain depending on luid loading negatively affect body image of patients undergoing hemodialysis [6,7].These losses experienced by patients undergoing hemodialysis in numerous parts of life affect negatively life satisfaction by causing several adjustment disorders [4].
Life satisfaction has an important role in various aspects of life.Life satisfaction which is an important determinant for mental well-being signi ies evaluation of life aspects https://doi.org/10.29328/journal.jnpr.1001032based on inner world [1].These assessments include all responses of emotional quality to incidents, mental processes, and judgments of satisfaction in different aspects of life such as job, education.Life satisfaction is associated with accepting and continuing medical treatment voluntarily.This condition may affect course and symptoms of disease [8].Patients undergoing hemodialysis treatment are observed to experience social limitations, and also have several physical pains due to their disorder.This change in their lives may decrease their life satisfaction depending on the ef iciency of coping strategies they use [9].Studies reveal that in addition to the strong correlation between individual's assessment of life satisfaction and health perception, high life satisfaction is an important determinant also for positive results after medical disorder [1,9].

Materials and methods
This descriptive study was conducted in order to determine body image perception and life satisfaction of individuals undergoing hemodialysis treatment.

Objectives
To determine body image perception and life satisfaction levels of individuals undergoing hemodialysis treatment.
To determine factors affecting body image perception and life satisfaction.
To reveal the correlation between body image perception and life satisfaction.

Design
The population of the study consisted of individuals who were treated in hemodialysis units in the city center of Kırşehir.Totally 180 patients including 70 patients who were undergoing dialysis in hemodialysis unit of Training and Research Hospital and 110 patients who were undergoing dialysis in a private dialysis center, constituted the population of the study.It was planned to include whole of the population by using whole number method, but patients, who did not agree to participate in the study and did not meet inclusion criteria of the study, were excluded from sample and the study was conducted with 135 patients between 23 January and 1 June 2016.

Inclusion criteria
Individuals who were older than 18, were receiving hemodialysis treatment at least for 6 months, were undergoing hemodialysis session three times a week, had no mental problem that may prevent to participate in the study, were capable of communicating, and agreed to participate in the study, were included in the study.

Instruments
As data collection tool, questionnaire [1,2,6,9,10] consisting of 30 questions including socio-demographic and disease characteristics of the patients which was prepared by the researcher upon review of related literature, multidimensional body-self relations questionnaire (MBSRQ), and satisfaction with life scale )SWLS) were used.

Multidimensional Body-Self Relations Questionnaire (MBSRQ)
The questionnaire was developed by Winstead and Cash in [11] in order to conduct multidimensional examination and assessment of body image.Validity and reliability study of the scale in Turkey was conducted by Selma Doğan and Orhan Doğan [12] and Cronbach's Alfa internal consistency coef icient was determined as α = 0.94.The scale has 57 items and 7 subscales (evaluation of appearance, orientation of appearance, evaluation of itness, orientation of itness, health evaluation, orientation of health, and satisfaction with body areas).15 reversed items are found in 5-point likert type scale (1 = strongly disagree, 5 = strongly agree), the lowest and highest scores of the scale are respectively 57 and 285.High scores signi ies a healthy body and high self-image.

Satisfaction With Life Scale (SWLS)
The scale, which was developed by Diener, et al. (1985) in order to determine individuals' life satisfaction level, consists of 5 items containing answers ranging from "strongly disagree" to "strongly agree" [13].Each item is scored between 1 and 7 and total score ranges from 1 point to 35 points.A high score obtained from the scale indicates that individuals' life satisfaction level is high.Turkish validity and reliability of the scale was conducted by Köker [14] and Yetim [15].In the study of Yetim, it was reported that Cronbach's Alfa of the scale was 0.86 and test-retest reliability was 0.73.
Cronbach's Alfa internal consistency coef icient in this study was determined as 0.88 for MBSRQ and 0.89 for SWLS.

Procedure
The data of the study were collected from the patients by using face to face interview technique.The patients were informed about the study and their verbal and written consents were received.

Data analysis
All statistical analyses were performed with IBM Statistical Package for the Social Sciences [SPSS] Statistics 21 software, 2012.Percentage calculation; chi-square; student t test or Mann-Whitney U test for the analysis of difference between means of two groups; one way analysis of variance [ANOVA] or Kruskall-Wallis variance analysis for comparison of means of more than two groups; and Pearson correlation analysis for determining correlation between continuous variables were used as statistics.

Ethical considerations
Before starting the study, Ethics Committee Approval https://doi.org/10.29328/journal.jnpr.1001032(2016-01/06) from Non-invasive Trials Ethics Committee Unit of a University and written permissions from institutions where the study was conducted were received.

Results
It was determined that 60.0% of individuals included in the study were women, 51.9% were in age group of 65 years and older, average age was 64.9 ± 11.8, 43.7% were primary school graduates, 87.4% were married, 52.6% had nuclear family, 48.9% had general health insurance (SII), 91.9% were unemployed, 75.6% stated their income status were middle, and 59.3% were in urban area (Table 1).
As stated in table 1, the individuals were CRF patients averagely for 78.61 ± 49.82 months and were undergoing hemodialysis treatment for 71.21 ± 46.93.It was found that 84.4% of the individuals' vascular insertion site had arteriovenous istula, BMI of 47.4% was normal, and transplantation was not planned for 60.0%.MBSRQ mean score of the patients, undergoing hemodialysis, in this study was 93.42 ± 07.Table 1 shows MBSRQ total mean scores of the individuals in terms of their descriptive characteristics.As the related table was examined; it was determined that difference between total MBSRQ mean scores of the of individuals in terms of gender, age groups, educational level, family structure, employment status, and income status was statistically signi icant (p < 0.05).According to the study result, MBSRQ total mean scores were signi icantly low in those who were women, were older than 65, were illiterate, had an extended family, were unemployed, had very low income status.The difference between MBSRQ total mean scores of the individuals in terms of marital status was not statistically signi icant (p > 0.05).
When MBSRQ total mean scores of the individuals were examined in terms of their disease characteristics; it was found that the difference between total mean scores of the individuals was statistically signi icant in terms of disease and hemodialysis time, vascular insertion site, body mass index, and transplantation history (p < 0.05).MBSRQ total mean scores of the individuals, who had disease for 10 years and longer and underwent hemodialysis treatment, whose vascular insertion site had arteriovenous istula, had body mass index in class of morbid obese, had no planned transplantation, were signi icantly low (Table 2).
As a result of this study, SWLS mean score of the patients was found as 19.2 ± 5.4.Age, educational status, employment status, and income status among socio-demographic characteristics of patients were determined to cause a signi icant difference on life satisfaction.SWLS mean scores of the individuals who were in age group of 25-34 years, were high school graduate, were employed, and stated their income status as very high were determined to be signi icantly high.It was determined that gender, marital status, and family type did not affect SWLS mean score signi icantly (Table 1), (p > 0.05).
When correlation between disease characteristics and life satisfaction of individuals was examined; it was found that while SWLS mean score was signi icantly high in individuals who had CRF disease for 6-12 months, were undergoing hemodialysis for 6-12 months, were waiting for renal transplantation, body mass index did not affect life satisfaction (Table 2).
As a result of the correlation analysis made between body image and life satisfaction, it was determined that there was a positive, quite signi icant correlation.Consequently, as mean score obtained by the patients from multidimensional bodyself relations questionnaire decreased, their mean scores of the satisfaction with life scale also decreased (Table 3).

Discussion
The results showed that hemodialysis patients have some levels of body-image disturbance.Also, researches indicated that the level of body-image disturbance is higher among hemodialysis patients as compared with kidney transplant patients and continuous ambulatory peritoneal dialysis patients [2,16,17] .
Although impaired body image is a common psychological consequence of living with hemodialysis studies about the effects of hemodialysis on KBY patients' body image are very limited.
According to results of the study, self-esteem, body image and life satisfaction levels of female patients were found to be lower compared to male patients.As stated in the literature, women mainly attach importance to aesthetical values; whereas men mainly attach importance to social image [18].This result made us think that women were affected by diseases more compared to men, they integrated functional loss of an organ with appearance of the body regardless of being visible, and they were less satis ied with their body integrity.
While previous studies state that mean score of body image was higher in advanced age group, mean scores of body image and life satisfaction were determined to be higher in young adult individuals in the present study, which was in contrast to literature [2,6].Young patients' having many expectations about their future and desire of ful illing these expectations positively affect their attitudes and approaches to treatment.
According to results of the study, it was remarkable that mean scores of MBSRQ and SWLS increased as educational  level increased.Previous studies also reported that satisfaction level of body image in patients with higher educational level was higher [10,17].It was thought that educational level positively in luenced coping mechanisms of patients and indirectly increased MBSRQ and SWLS.
In the present study, MBSRQ and SWLS scores of those, who described their income status as very high and were employed, were higher than MBSRQ and SWLS scores of those, who described their income status as very low and were unemployed, in a statistically signi icant manner.This result was found to be compatible with results of other studies that revealed the effect of economic status on life satisfaction [1,19].It is stated in the literature that existence of economic support, which needs to last for lifelong, relieves individuals and their family and makes adaptation of individuals easier against disease process compared to those without insurance [17].
MBSRQ and SWLS mean scores of the individuals living in an extended family were found to be higher than those living in a nuclear family.It is stated that social support positively in luences physical and mental well-being directly by meeting basic needs such as love, compassion, self-esteem, and belonging to a group [20].According to these results; it can be asserted that individuals receiving higher family support adapt disease and experienced problems more easily.It is mentioned in the literature [21,22] social support brings healthy coping to individual, decreases feeling of hopelessness and depression, increases personal suf iciency during stress periods, provides emotional balance, and brings life satisfaction and psychological well-being.
It was found that duration of disease and dialysis time caused a signi icant difference on body image and life satisfaction.In advancing times of hemodialysis treatment, patients mostly live together physical/mental complications induced by chronic disease and hemodialysis and concern about their lives under threat is common.It is stated there is an adaptation period for patients who start to undergo dialysis in irst years of CRF treatment and patients try to get used to a new way of treatment and to regulate their lives according to this new way of treatment in this period [23,24].For this reason, MBSRQ and SWLS mean scores of the individuals can be thought to be high at early times of treatment.
MBSRQ mean scores of the individuals having arteriovenous istula in vascular insertion site were determined to be lower compared to individuals with port catheter.It is required to ind an appropriate way of vascular access in order to provide suf icient HD treatment to patients.Temporary catheterization, permanent catheterization, and arteriovenous [AV] istula were used as vascular access in patients starting to undergo hemodialysis.AV istulas with the rate of 83.6% are the most frequent vascular access used for hemodialysis [25].Therefore, life length and quality of individual receiving HD treatment are directly related with vascular access route.Presence of local complications such as hemorrhage in early period, thrombosis in late period, extremity edema, ischemia of extremity, aneurysm, and graft infection following arteriovenous istula surgery may cause individuals to have impaired body image [26].
It was determined that MBSRQ mean scores of individuals whose body mass index were classi ied overweight, obese, and morbid obese were signi icantly low, but BMI did not affect life satisfaction.Previous studies emphasized that body image satisfaction of obese people was very low, and as BMI increased, self-esteem decreased [27,28].
According to result of the study, existence of positive correlation between body image perception and life satisfaction is compatible with data of literature [29].It was reported in previous studies that life quality and life satisfaction of individuals with high body image perception were high [4,5].Body image satisfaction and life satisfaction are closely associated with the nature and status of physical and mental health of the individuals.The review of the literature demonstrated that physical and mental health conditions signi icantly affect body image satisfaction and life satisfaction of the individuals.
In conlision, body image and life satisfaction are an important issue among hemodialysis patients that has not been paid enough attention by now.Health care team members working with this group of patients should be aware of this important issue and conduct psychological programs to decrease the level of body image disturbance and life satisfaction.It is recommended to plan an experimental study evaluating ef iciency of practices or interventions of nurses, who provide care to patients undergoing hemodialysis, for diagnosis of impaired body image in such patients.

Table 1 :
Comparison of the Individuals' MBSRQ and SWLS Total Mean Scores in Terms of Their Descriptive Characteristics.

Table 2 :
Comparison of the Individuals' MBSRQ and SWLS Total Mean Scores in Terms of Their Disease Characteristics.While the same letters indicate lack of diff erence, diff erent letters indicate presence of diff erence. *

Table 3 :
Correlation Coeffi cient of Multidimensional Body-Self Relations Scale and Satisfaction With Life Scale Scores of Individuals. https://doi.org/10.29328/journal.jnpr.1001032