key: cord-0744660-ktj85b7f
authors: Dehghan, Mahlagha; Namjoo, Zakieh; Mohammadi Akbarabadi, Fatemeh; Fooladi, Zahra; Zakeri, Mohammad Ali
title: The relationship between anxiety, stress, spiritual health, and mindfulness among patients undergoing hemodialysis: A survey during the COVID‐19 outbreak in Southeast Iran
date: 2021-12-14
journal: Health Sci Rep
DOI: 10.1002/hsr2.461
sha: 58884fd31cc6dd0571db8e108fc55f1ff3fc20d5
doc_id: 744660
cord_uid: ktj85b7f

BACKGROUND AND AIMS: Hemodialysis patients are prone to high stress and anxiety related to the acute coronavirus epidemic. Mindfulness and spiritual health are among the factors associated with stressful and anxious situations. The current study aimed to investigate the relationship between mindfulness, spiritual health, and coronavirus stress/anxiety in patients undergoing hemodialysis. METHODS: One hundred and forty‐four patients underwent hemodialysis participated in this cross‐sectional study. Patients completed the Demographic and Clinical Characteristics Form, Corona Disease Anxiety Scale (CDAS), stress subscale of DASS‐21, The Freiburg Mindfulness Inventory‐ Short Form (FMI‐SF), and Spiritual Health Scale. RESULTS: The results showed that 28.5% of the participants had moderate to severe anxiety. According to the psychological symptom subscale (CDAS), 54.2% of the participants had moderate to severe anxiety. According to the physical symptom subscale, 41.7% of the participants had moderate to severe anxiety. Sixteen percent of the patients believed that the coronavirus disease 2019 (COVID‐19) outbreak and lockdown influenced their course of treatment. A significant association was found between coronavirus disease anxiety and mindfulness (r = −0.20, P < .05). No significant association was found between stress and mindfulness/spiritual health (P > .05). CONCLUSION: The results of this study showed that coronavirus anxiety and stress are common in hemodialysis patients. Mindfulness may be effective in reducing coronavirus anxiety in hemodialysis patients. Therefore, interventions are suggested to increase the level of mindfulness and empower hemodialysis patients to cope with anxiety caused by crises such as the coronavirus outbreak.

Coronavirus disease 2019 was detected in China at the end of 2019 and quickly became a pandemic in the world. 1 This disease has had various destructive effects on mental health in China and the world. During the initial phase of the COVID-19 outbreak in China, more than half of the respondents rated the psychological impact as moderate to severe, and about one-third reported moderate-to-severe anxiety. 2 It had the highest Impact of Event Scale-Revised (IES-R), stress, anxiety, and depression scores in some nations, such as Thailand. 3 Furthermore, Poland and the Philippines were the two countries with the highest levels of anxiety, depression, and stress. 4 Some studies have reported numerous mental disorders due to the prevalence of COVID-19 disease and the effects of quarantine in the community. 5 In Iran, high levels of anxiety, stress, 6 and fear have been reported. 7 According to the World Health Organization (WHO) on April 27, 2020, 109 577 laboratory-confirmed COVID-19 incidents, which included 3809 deaths, were widely reported in China and 28 673 incidents in 104 other countries. 8 Less than half of the patients had underlying diseases such as diabetes, hypertension, and cardiovascular disease. 1 One of the underlying diseases is chronic kidney disease and chronic end-stage failure, which seems to be associated with an increased mortality rate in these patients during coronavirus outbreak. 9 COVID-19 disease has had significant effects on chronic patients, including rheumatoid arthritis, systemic lupus erythematosus, 10 and renal patients. 11 End-stage renal disease (ESRD) is a clinical condition in which the kidneys fail to perform metabolic functions and maintain fluid and electrolyte balance in the body. The ESRD is a common physical disease that affects 2% to 3% of the global population. Patients need alternative therapies, including dialysis, to survive. Hemodialysis is currently the most common alternative treatment for these patients. 12 A high percentage of stress and anxiety is reported in chronic patients. 13 In addition to chronic disease, hemodialysis patients face many stressors, including problems with treatment, dietary and fluid restrictions, weakness, anxiety, and depression. 14 Stress is associated with all psychological factors and increases the rates of depression, anxiety, and other forms of mental disorders in different patients.

Anxiety and stress can physiologically affect the functioning of the immune system and predispose a person to any physical or mental illness by reducing the body resistance. 15 Unfortunately, the prevalence of depression, anxiety, and stress in patients undergoing hemodialysis is currently increasing, which can affect the mental and physical health of these people and also disrupt their course of treatment. 16 Thus, stress and anxiety can weaken the immune system and make a person vulnerable to diseases such as coronavirus. COVID-19 anxiety is common because people do not know such a disease well, and they are worried about the future. 17, 18 Mindfulness-based cognitive therapy and spiritual health can be used to improve stress and anxiety. 19 Mindfulness is limited to the present moment without judgment and requires alertness, constant concentration, and openness of mind.

Mindfulness will lead to nonpainful insights because fully conscious experiences will lead to stable acquisition of basic experiences. 20 Mindfulness, instead of intensifying various pressures and stresses, predisposes to psychological growth, well-being, and health in people and is a way to live better, relieve pain, enrich, and make life meaningful and reduce stress in the short and long term. 21 Thus, mindfulness is a balanced mental framework that avoids emotional and unpleasant magnifications and provides an opportunity to keep one away from emotionally unpleasant states. 21 Spirituality is another human capability that offers problemsolving and coping strategies. In addition, spirituality as a source of social support creates a meaningful sense of coping with confusion and natural disasters and increases a sense of indirect control over events. 22 Many physicians today consider faith and spirituality an important source of physical health, so they pay attention to patients' spiritual issues in the course of treatment. 23 Spiritual health can be defined as a sense of communication with others, a perception of the meaning and purpose of life, and a connection to a higher power that helps people live better and have more effective interactions with the world around them. 24 This dimension is one of the four dimensions of health. In addition to the physical, mental, and social dimensions, spiritual health promotes public health and coordinates other dimensions of health. 25 Spirituality, a common strategy in coping with problems and diseases, has many roles and effects on the mental and physical health of people. 26 Concerning the effect of spiritual health and mindfulness on promoting adaptation to chronic diseases, COVID-19 stress and anxiety, and the limitations of such studies on dialysis patients, the present study aimed to investigate the relationship between mindfulness, spiritual health, coronavirus stress, and anxiety in patients undergoing hemodialysis.

This was a cross-sectional and analytical study. The research settings were two hemodialysis centers (Shafa hospital and Javad Alaemeh Clinic) affiliated to Kerman University of Medical Sciences in the southeast Iran.

The study population consisted of all eligible patients under hemodialysis who were referred to the research settings. Inclusion criteria:

(a) age above 18 years, (b) patients undergoing chronic hemodialysis, (c) the necessary skills to communicate effectively, and (d) reading and writing skills. Exclusion criterion is failure to complete more than 10% of each of the questionnaires.

From 208 patients under hemodialysis in Javad Alaemeh Clinic, 149 participants were eligible to participate in the study. Forty-four participants declined to participate, and 16 participants did not complete the questionnaire; therefore, 89 participants fulfilled the questionnaire. In the Javad Alaemeh Clinic, the response rate was 59.73%.

From 108 patients under hemodialysis in Shafa hospital, 82 participants were eligible to participate in the study. Nineteen participants declined to participate, and eight participants did not complete the questionnaire; therefore, 55 participants fulfilled the questionnaires.

The response rate in the Shafa hospital was 67.07%. Finally, the total sample size of the study was 144. 27 The CDAS has a goodness of fit index according to the confirmatory factor analysis.. 27 In the present study, the Cronbach's alpha of CDAS was 0.93.

The 21-item Depression, Anxiety and Stress Scale (DASS) was developed by Lovibond in 1995 to measure stress-anxiety-depression.

DASS-21 was validated in different cultures such as Spain, 28 the United States, 29 Poland, 30 Chinese, 31 Vietnam, 32 34 In the present study, the Cronbach's alpha of FMI-SF was 0.81.

The spiritual health scale of Palutzian and Ellison (1928) consists of 20 items with two subscales of religious health (10 items) and existential health (10 items). The items were about how much participants engage in spiritual health on a 6-point Likert scale, ranging from 1 (strongly disagree) to 6 (strongly agree). The score of spiritual health was the sum of the two subscales ranging from 20 to 120. The scores of 20 to 40, 41 to 99, and 100 to 120 show low, moderate, and high spiritual health, respectively. Its validity and reliability have been confirmed (Alpha coefficient = 0.82). 35 In the present study, the Cronbach's alpha of the spiritual health scale was 0.83.

The researchers referred to the centers after obtaining the code of ethics from the ethics committee. After selection of the eligible patients, clarification of the purpose of the study, and acquisition of the written consent from the patients, the ESRD patients completed the questionnaire when they were in a good physical condition. Questionnaires were collected during dialysis. The researchers interviewed uneducated patients to complete the questionnaires. The data were collected during 1 month (from August 15 to September 15, 2020).

Data were analyzed using the IBM Statistical Package for Social Science (SPSS) version 25.0 (SPSS, Inc., Chicago, Illinois). Frequency, percentage, median, interquartile range, mean, and standard error were used to describe the sample characteristics, the CDAS, stress, mindfulness, and spiritual health scores. Spearman's rho correlation coefficient was used to check the correlations between CDAS, stress, mindfulness, and spiritual health scores. Since the parametric conditions were not established, Mann-Whitney U and Kruskal-Wallis H tests were used to check the association between qualitative variables, CDAS, and stress scores. The significance level was considered to be <.05.

The code of ethics (IR.KMU.REC.1399.342) was received from the Ethics Committee of Kerman University of Medical Sciences. The researchers referred to the centers after obtaining approval from the concerned hospital. In this project, the purpose of the research was fully explained to the participants, who could withdraw from the study at any time. They were explained that participating in or withdrawing from the study would not affect their course of treatment, and all their information would remain confidential.

The mean age of the participants was 59.11 ± 13.60 years (Min = 25 and Max = 87). The majority of the samples were male, married, educated, and unemployed. The majority of the participants were insured ( Table 1 ). The clinical characteristics of the participants are presented in Table 2 . Only seven patients were infected with COVID-19, and No significant correlation was found between CDAS and spiritual health, but there was a negative weak correlation between CDAS and mindfulness. No significant correlation was found between stress, spiritual health, and mindfulness. There was a significant moderate correlation between mindfulness and spiritual health (Table 4) .

Female patients had greater anxiety than males (P < .05). The CDAS score did not differ in other qualitative variables (Tables 1 and 2) . Stress scores were significantly higher among patients aged 50 to 70 years old than others (P < .05). Female patients had greater stress than males (P < .05). The divorced/widowed had higher stress than married and single ones (P < .05). Patients referred to Shafa hospital had higher stress than those who were referred to Javad Alaemeh clinic (P < .05) (Tables 1 and 2 ).

For therapeutic goals and effectiveness, it will be helpful to know how hemodialysis patients cope with anxiety and stress in stressful situations, 36 health, coronavirus stress, and anxiety in hemodialysis patients. A review of the literature shows that it is the first study that examines the correlation between mindfulness, spiritual health, coronavirus stress, and anxiety in hemodialysis patients.

The present study showed a weak negative correlation between coronavirus anxiety and mindfulness. Yang et al also showed that mindfulnessbased stress therapy reduced depression and anxiety in hemodialysis patients. 37 Internet CBT can treat psychiatric symptoms during COVID-19. 41 Internet CBT is a cost-effective method 42 that can treat psychiatric symptoms such as insomnia. 43 Furthermore, Dehghan et al showed that perceived stress was not related to mindfulness. 44 In some chronic patients, such as cancer patients, no significant association was found between corona disease anxiety and mindfulness. 45 According to the results of the present study, mindfulness can be used as an adjunctive intervention to manage emotions and reduce anxiety in crises such as coronavirus disease, but it has no effect on stress.

Therefore, the present study shows a weak negative correlation between coronavirus anxiety and mindfulness and no correlation between mindfulness and stress. However, researchers consider the probability of influencing some other factors that have become significant in the present study, and these potential influencing factors should be considered. Therefore, the impact of these possible factors should be studied in further studies and in different communities.

Another result of the present study was the lack of association between coronavirus anxiety, stress, and spiritual health. Alshraifeen et al showed no significant correlation between spirituality, depression, and anxiety in hemodialysis patients. 46 In some chronic patients, such as cancer patients, no significant association was found between corona disease anxiety and spiritual health. 45 Hemodialysis patients use religious and spiritual beliefs and practices as a mechanism to overcome their depression, anxiety, and stress. 47 Muslim patients consider illness, pain, and suffering as a divine experiment that alleviates one's sins. 48 These results have been confirmed by other studies on Muslim hemodialysis patients. 46 Gurkan et al found that turning to religion was the most common strategy of hemodialysis patients to cope with anxiety and depression. 36 According to Gurkan, Turkish hemodialysis patients are more likely to use religious coping than Western ones. 36 In the present study, women were more anxious and stressed.

The divorced/widowed were also under a lot of stress. In line with the results of the present study, Martinez et al showed that the highest rate of psychological stress was observed in hemodialysis women. 49 In addition, Alshraifeen et al in Jordan showed that lower levels of education and more illnesses were associated with more anxiety in hemodialysis patients. 46 Gholami et al showed that variables of living place, comorbidity, and age were the predictors of death anxiety in hemodialysis patients. 50 The results show that several factors are involved in the anxiety and stress of hemodialysis patients. Depression and anxiety are the most common psychological complications of hemodialysis patients due to the many problems associated with the disease, such as loss of freedom, life expectancy, energy, job, income, and sexual ability. 51 Therefore, the attention of health care providers plays a supportive role in improving the health status of patients and helping improve coping mechanisms in patients with kidney problems.

Further detailed studies are required on anxiety and stress in hemodialysis patients and the various factors affecting them. 

The results of this study showed that coronavirus anxiety and stress were among the most common and significant negative emotions in Iranian hemodialysis patients. Mindfulness may be effective in reducing coronavirus anxiety in hemodialysis patients, and spirituality has no effect on anxiety and depression. According to the obtained results, it is suggested to pay special attention to the constructs of mindfulness to increase the level of mindfulness, cope effectively with stresses and stressors, and empower hemodialysis patients. It is also suggested that other factors related to anxiety and depression in hemodialysis patients be evaluated in future research.

The results of this study showed that increasing mindfulness could be 

We would thank all patients for their cooperation. The approved research project code was 99000338.

No funding or research grant was received in the course of study.

The authors declare that they have no competing interests in this section.

Conceptualization: Mahlagha Dehghan.

Data collection and vuration: Zakieh Namjoo, Fatemeh Mohammadi

Akbarabadi, and Zahra Fooladi.

Formal analysis: Mahlagha Dehghan.

Zakeri.

Writing-Original draft: Mohammad Ali Zakeri.

All authors have read and approved the final version of the manuscript.

Mohammad Ali Zakeri had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.

The Mohammad Ali Zakeri affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

The data used to support the findings of this study are available from the corresponding author upon request.

The code of ethics (IR.KMU.REC.1399.342) was received from the Ethics Committee of Kerman University of Medical Sciences.

https://orcid.org/0000-0002-4205-829X

Mohammad Ali Zakeri https://orcid.org/0000-0003-1500-391X

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