key: cord-0729144-3o6ynd43
authors: DOĞAN, Runida; SERİN, Emine Kaplan; BAĞCI, Nazlıcan
title: Fear of COVID 19 and social effects in liver transplant patients
date: 2021-10-07
journal: Transpl Immunol
DOI: 10.1016/j.trim.2021.101479
sha: 966dfeb5d345c62f94a09b503b2786cf1de39b21
doc_id: 729144
cord_uid: 3o6ynd43

BACKGROUND: This study was descriptively conducted to evaluate the fear of COVID 19 and its social effects on patients who had liver transplant. METHODS: The study was conducted between September 2020 and April 2021 in a liver transplant institute affiliated with a university hospital. The sample of the study was 135 patients. Personal Information Form, Fear of Covid 19 Scale, and Questionnaire of Social Impact of COVID 19 Pandemic were used to collect data. RESULTS: It was determined that the Fear of Covid 19 Scale mean score of the patients was 21.25 ± 6.99. As the fear of COVID 19 increases in patients who had liver transplant, it was determined that their desire to be in crowded environments, to prefer public transportation, to go to the doctor for examination and their focusing on various objectives were decreasing. Also, fear of COVID 19 increased the difficulty in sleep, storage of food and cleaning materials, washing hands frequently, using masks and gloves when going out, health concerns, doubts about disease symptoms, orientation towards healthy eating, worries about the future and questioning the meaning of life. CONCLUSION: The results show that it is important for transplant centers to be able to provide guidance and psychological counseling services to liver transplant patients, who are significantly affected by COVID 19, through telemedicine or various technological opportunities.

The coronavirus (COVID- 19) , which emerged in Wuhan, China in December 2019 and caused a pneumonia-like symptom, spread to many countries of the world in a short time and was declared as a pandemic by the world health organization [1] . In a short time, many people caught Covid 19 and died [2] . It is known that COVID-19, which has the potential to cause mortality and morbidity in many people, poses a higher risk for some groups. Among these groups, the elderly, diabetic patients, hypertensive patients, chronic kidney disease patients, obese individuals, coronary heart patients, chronic lung patients and those receiving chronic immunosuppression therapy are the leading ones. So much so that the case fatality rate has been reported to reach up to 49% in risky groups [3] .

The COVID-19 pandemic has not only affected people physiologically, but suspicious information about virus transmission, incubation time, geographic coverage, number of infected and actual mortality has also caused serious psychological problems in the population. "Fear" has an important place among the main psychological problems [4] [5] [6] .

Fear, defined as "an uncomfortable and negative feeling triggered by the perception of threat in the face of an uncertainty" increases various psychological symptoms and can also motivate a series of behaviors that reduce participation in risky behavior (for example, hand washing, social distancing) [1, 5] . According to the motivation theories among the theories about fear, there is an inverse proportion between fear and behavior change, and it is suggested that more behavior changes will occur at a moderate level of fear [7] . The most recent of the fear item theories is Witte's Extended Parallel Process Model, which brings together classical fear item theories. According to this model, people's response to fear items is based on how they evaluate and perceive the threat. When evaluating the threat, the target audience considers the seriousness and severity of the threat, as well as the vulnerability and the possibility of its occurrence. If people do not believe they are at risk or see the health J o u r n a l P r e -p r o o f Journal Pre-proof threat as serious, they will not respond to the message [7] . When people are afraid but can respond effectively to the threat, they accept the recommended action to control the danger.

On the other hand, if the perception of threat exceeds the perception of competence (that is, if the recommended action is too difficult, too expensive, or they believe they are not enough to fend off the threat), people begin to focus on how to control their fears. They ignore the message, deny that they are at risk, make fun of the message or get angry with the source, and even increase their unhealthy behavior [5, 8] . In a conducted study, it was found that there was a positive correlation between fear of COVID 19 and increase in behavior change [1] . In another study, it was found that patients who received more intense immunosuppression therapy had higher fear of COVID 19 and changes have occurred in many healthy or unhealthy behaviors [6] .

Liver transplant recipients are known to represent vulnerable patient groups at high risk of infection [6] . When the literature is reviewed, only one study examining the fear of COVID-19 in liver transplant patients, a group at high risk for COVID-19, and the social effects of this fear was found [6] . As it is known, nurses are a professional group that deals with individuals with their biological, psychosocial dimensions and environment, and is in constant interaction with the healthy / sick individual, and undoubtedly, they have an important place in the process of feeling and managing the tension, panic feelings and fears of patients [9, 10] . Little is known about the COVID-19 fear and social impact of the COVID-19 pandemic in vulnerable patient groups [11] . In this context, the study was conducted to determine the This study was conducted descriptively to evaluate the COVID 19 fear and social impact of this fear in liver transplant patients.

The study was conducted between September 2020 and April 2021 in the outpatient clinics of a liver transplant institute affiliated to a university hospital. The liver transplant institute has 5 polyclinic rooms, 12 operating rooms, 3 intensive care units with a total of 36 beds, 7 patient services with a total of 116 beds, a radiology unit and a gastroenterology-ERCP unit.

Approximately 270 patients receive liver transplantation annually at the institute.

The population of the study consisted of all patients who were followed up after liver transplantation in outpatient clinics of the liver transplant institute. The sample of the study consisted of the patients who came to the outpatient clinic for control and met the inclusion criteria. The sample group was calculated using power analysis. According to the calculation, the sample size was determined as 111 with 0.30 effect size, 0.05 error margin, 0.95 confidence level, and 0.95 population representation power. 135 patients were included in the study. 

After the data were coded by the researchers, the statistical analysis of the data was performed using SPSS 25.0 (Statistical Package for The Social Sciences) statistical software.

In the statistical evaluation of the data, its suitability to normal distribution was tested with the Shaphiro Wilk test, and it showed a normal distribution. Descriptive features in the study are presented with number (n), percentage (%), mean (x), standard deviation (SD), median, minimum, and maximum values. In the comparison of scales and descriptive characteristics, independent t test and ANOVA were performed. Bonforrenia analysis was used to determine the difference in multiple comparisons. Correlation and linear regression analysis (stepwise method) were performed to determine the relationship between scales. Scale Reliability Coefficient was determined in terms of Cronbach's Alpha. In evaluating the results obtained, 95% confidence interval and p<0.05 error level were considered.

J o u r n a l P r e -p r o o f

Ethics committee approval required to conduct the research (Decision Number: 2020/974) and institutional permission were obtained. Verbal consent was obtained from the individuals participating in the study, and the individuals were informed that their information would not be shared with others, that they were free to participate in the study and that they could leave the study whenever they wanted. Thus, the ethical principles of "protection of patient rights", "confidentiality" and "informed consent" were complied with.

The limitations of the study are the fact that the sample consists of patients receiving treatment in only one hospital and the sample was determined by the improbable random method. Study results cannot be generalized to all liver transplant patients.

It was determined that the average age of the patients was 47.39±15. 24 Figure 1 ).

J o u r n a l P r e -p r o o f The average score obtained from Fear of Covid 19 Scale in patients with acute liver failure due to transplantation is higher than the others, and the difference between them is statistically significant (Table 1; Figure 2 ). Figure 3 ). J o u r n a l P r e -p r o o f Table 2 shows the Comparison of Patients with the Social Impacts of the COVID-19

Pandemic and the Fear of COVID-19. The statistical difference between the desire of the patients to be in a crowded environment and the Fear of Covid 19 Scale average score is significant. As a result of the Bonferroni analysis, it was determined that this difference was between "very reduced" and "unchanged", "very reduced" and "reduced". The statistical difference between the desire of the patients to prefer public transportation and the Fear of Covid 19 Scale average score is significant. As a result of the Bonferroni analysis, it was determined that this difference was between "very reduced" and "reduced". The statistical difference between the food and cleaning materials storage status of the patients and the Fear of Covid 19 Scale average score is significant. As a result of the Bonferroni analysis, it was found that this difference was between "not changed much" and "much increased", "increased" and "much increased". The statistical difference between the frequent washing of the hands of the patients and the Fear of Covid 19 Scale average score is significant. As a result of the Bonferroni analysis, it was determined that this difference was between "increased" and "much increased". The statistical difference between the use of masks and gloves while going out and the average Fear of Covid 19 Scale score is significant. As a result of Bonferroni analysis, it was determined that this difference was between "increased" and "much increased". The statistical difference between the patients' going to the doctor for examination and the Fear of Covid 19 Scale average score is significant. The Bonferroni analysis result found that the difference is between "very reduced" and "unchanged." The statistical difference between the health concerns of the patients and the Fear of Covid 19

Scale mean score is significant. As a result of Bonferroni analysis, it was determined that this difference was between "unchanged" and "increased", "not changed" and "much increased", "increased" and "much increased". The statistical difference between the doubts of the patients about the symptoms of the disease and the Fear of Covid 19 Scale average score is J o u r n a l P r e -p r o o f significant. As a result of the Bonferroni analysis, it was determined that this difference was between "unchanged" and "increased", "not changed" and "much increased", "increased" and "much increased". The statistical difference between the patients' orientation to healthy nutrition and the Fear of Covid 19 Scale mean score is significant. As a result of the Bonferroni analysis, it was found that this difference was between "unchanged" and "much increased", "increased" and "much increased". The statistical difference between the difficulty of sleeping and the Fear of Covid 19 Scale mean score is significant. As a result of the Bonferroni analysis, it was determined that this difference was between "increased" and "much decreased", "not changed". The statistical difference between the patients' concerns about the future and the Fear of Covid 19 Scale average score is significant. As a result of the Bonferroni analysis, it was determined that this difference was between "unchanged" and "increased", "not changed" and "much increased", "increased" and "much increased". The statistical difference between focusing on the goals of the patients and the Fear of Covid 19

Scale average score is significant. As a result of the Bonferroni analysis, it was found that this difference was between "much decreased" and "unchanged", "much decreased" and "increased", "decreased" and "unchanged". The statistical difference between the patients questioning the meaning of life and the Fear of Covid 19 Scale average score is significant.

As a result of the Bonferroni analysis, it was determined that this difference was between "unchanged" and "increased", "unchanged" and "much increased".

In Table 3 J o u r n a l P r e -p r o o f 

COVID-19 creates an important fear in the society due to its rapid spreading feature and causing serious morbidity-mortality. The resulting fear also brings various social effects [14] .

It is difficult to determine the need for education and prevention programs without knowing the level of fear that may vary depending on certain variables and its social effects [14] . When the literature is reviewed, only one study has been found that examines the fear of COVID-19

and its social effects in liver transplant patients in the risk group [6] . Therefore, the study results were discussed together with similar literature findings.

In this study, it was determined that liver transplant patients experienced high levels of fear of COVID-19. In another study conducted with liver transplant patients, 64% of the patients stated that they were afraid of COVID-19 [6] . Considering the studies conducted in cancer patients, it is seen that the level of fear of the patients is high [3, 15, 16] . Similar results are found in studies conducted with a healthy population [5, 17] . The study results show that the vast majority of people, whether they are in the risk group or not, suffer from the fear of COVID-19. The high level of fear in many groups is thought to be related to the easy transmission and prevalence of COVID-19 and the ongoing increase in mortality [5, 6] .

In this study, it was determined that women experienced higher levels of fear of COVID- 19 . In Reuken's study, it was determined that female liver transplant recipients experienced higher fear of COVID-19 [6] . Similar results are found when looking at other studies [17, 18] .

This reality may be related to women feeling more vulnerable or perceiving high risk. In fact, there is information in the literature that demographic variables are effective on perceived risk [18] . In addition, it is stated that women express their feelings of fear, etc. more easily [19] .

Patients with acute liver failure as the reason for transplantation were found to have higher fear of COVID-19 (Table 1 ; Figure 2 ). In another study, it was observed that the underlying liver disease did not make a difference in the COVID-19 score [6] . It is thought that this situation may be related to the traumatic events during the period when the patients experienced acute liver failure. It was found that patients with individuals around whom had COVID-19 experienced higher fear of COVID-19. Similarly, in another study, it was shown that those who live in areas with high COVID-19 cases experience more fear [17] . Hearing the news of people who are constantly caught or died of COVID-19 can increase the fear of COVID-19 by causing a higher perceived risk.

Ideally, fear motivates effective and protective actions [20] . But it doesn't always have this effect. For example, it has been stated that behaviors related to fear during the EBOLA epidemic in the past increased the rates of psychiatric symptoms and indirectly caused deaths [4] . For these reasons, it is considered to be of great importance to determine the fear and social effects associated with the COVID-19 pandemic.

It was determined that, after the COVID-19 pandemic, liver transplant recipients' preference for being in crowded places and public transportation decreased significantly (Table 2) , and this reality was associated with the increase in fear of COVID-19. In Reuken's study, it was determined that most of the liver transplant recipients left their homes less frequently than before the COVID-19 pandemic [6] . In another study, it was found that one of the most preferred methods of preventive behavior by people is avoiding public transport [18] . Research results can be evaluated as positive. Because it is known that "distance" is one of the most important issues to be considered since the beginning of the COVID-19 pandemic [21] .

In this study, food and cleaning material storage status of patients increased in more than half of the patients, and this increase is associated with the fear of COVID 19. It is observed J o u r n a l P r e -p r o o f that this situation is similar in the general population [8] . Modes of the transmission of COVID-19, result in individuals increasing their personal hygiene measures, and it is expected that the food / cleaning material shopping has increased [8] . Patients' frequent washing of their hands and wearing masks or gloves while going out has increased considerably and is associated with the fear of COVID-19. In other studies, it is seen that hand washing and using protective equipment increased [6, 18] . In Reuken's study, patients who reported their fear of being infected with COVID-19 tend to use personal protective equipment and wash their hands more frequently [6] . It is known that hand washing, wearing a mask and using personal protectors are of great importance in protecting against COVID-19 [21] . Therefore, the research results can be described as gratifying.

In this study, the rate of going to a doctor for examination decreased in about half of the patients, and healthy eating efforts increased in most of the patients. As the fear of COVID-19

increased, the situation of going to the doctor decreased and their tendency towards healthy eating increased. In Reuken's study, a large proportion of patients stated that they were afraid of going to the hospital and were more likely to skip or postpone medical visits, and it was found that this situation increased in relation to the fear of COVID-19 [6] . In another study, while efforts for healthy eating increased in more than half of the individuals in the general population, their willingness to go to a doctor for examination decreased significantly [8] .

While the increase in healthy nutrition effort is a positive result for liver transplant patients, the decrease in the rate of going to the doctor for examination can be considered as a negative result. It is known that a strong immune system is important in protecting against COVID-19.

Therefore, nutrition is important [22, 23] . On the other hand, liver transplant patients must undergo regular checkups, and the decrease in hospital checks associated with catching COVID-19 may adversely affect the health status of the patients.

It has been determined that the health concerns of liver transplant patients have increased significantly and associated with the fear of COVID-19. The increase in health anxiety is thought to be related to immunosuppression. In a study conducted by Reuken, it was determined that a patient discontinued immunosuppressive treatment without a doctor's recommendation [6] . As a result of the study, it was determined that some of the liver transplant patients had trouble sleeping and this situation was related to the fear of COVID-19. It is also supported by the literature that fear triggers insomnia by causing anxiety [24, 25] .

It is known that insomnia weakens the immune system and increases susceptibility to infection [26, 27] . Therefore, it should be an issue that should be focused on especially in organ transplant patients.

It was determined that the mean Fear of Covid 19 Scale score of the patients was 21.25 ± 6.99 (high). It has been determined that as the fear of COVID-19 increases in patients with liver transplantation, their desire to be in a crowded environment, their desire to prefer public

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