Introduction
Chronic kidney disease is an important global health concern. Hemodialysis is the primary treatment method for chronic kidney diseases. Patients undergoing hemodialysis experience a high level of disability, loss of function, and increased dependence on family members. Family caregivers play a critical role in the care and support of these patients. However, the caregiving demands and responsibilities can lead to significant care burdens, causing physical and mental health problems in caregivers and affecting the quality of patient care. Even prior to the COVID-19 pandemic, caring for patients with hemodialysis was a stressful experience. The pandemic exacerbated this care burden and caused caregivers to face additional concerns regarding the risk of infection in the hemodialysis centers. Patients undergoing hemodialysis are at a higher risk of mortality if they get infected with COVID-19. Furthermore, the pandemic-related restrictions increased caregivers’ responsibilities, reduced family communication, and increased the vulnerability of patients, all of which contributed to increased care burden on families. Given that nurses of patients in hemodialysis centers are in frequent contact with patients and their families, they can play a vital role in improving the quality of care and supporting families using interventions such as coping strategy training. Coping skills training has been shown to improve the understanding of stressful situations and positively affect the health of both patients and caregivers. Thus, this study aimed to investigate the effect of coping skills training on the care burden of family caregivers of patients undergoing hemodialysis.
Methods
This is a quasi-experimental study with a pretest-posttest design that was conducted in 2020 in the comprehensive treatment center for special diseases, affiliated to Birjand University of Medical Sciences. Participants were 60 family caregivers of patients undergoing hemodialysis (30 in the intervention group and 30 in the control group). The intervention consisted of six two-hour sessions of coping skills training on a weekly basis. The data collection was done before, immediately after, and one month after the intervention using three tools: A questionnaire surveying patients’ demographic information (age, sex, marital status, economic level, duration of disease, number of dialysis sessions, and hours of dialysis per week), a questionnaire surveying caregivers’ demographic information (age, sex, marital status, education level, occupation, history of chronic diseases, type of relationship with the patient, and financial status), and the Zarit burden interview (ZBI), with 22 items, rated on a 5-point Likert scale from never (0 points) to always (4 points). The ZBI score ranges from 0 to 88, with higher scores indicating a greater care burden; a score of 0-20 indicates low burden, a score of 21-40 indicates mild to moderate burden, a score of 41-60 indicates moderate to severe burden, and a score of 61-88 indicates severe burden. The ZBI evaluates the caregiver burden in two domains: subjective burden and objective burden. The objective burden subscale assesses the negative effects of the disease, such as disruption in family relations, limitations in social, work-related, and recreational activities, and financial problems. The subjective burden subscale assesses caregivers’ emotional reactions to the patient and care. Data analysis was conducted in SPSS software, version 19 using the Chi-square test, Fisher’s exact test, independent t-test, repeated analysis of variance, Bonferroni post hoc test, and Mann-Whitney U test.
Results
There was no significant difference between the intervention and control groups in terms of demographic information (P>0.05). The ZBI score in both groups was moderate to severe before the intervention. The ZBI score in the intervention group showed a significant decrease after the coping skills training compared to baseline (P<0.001). Furthermore, the total ZBI score and the scores of objective and subjective burdens significantly decreased in the intervention group after the intervention (P<0.001), but no statistically significant difference was observed in the control group. The analysis of variance indicated a significant difference in the total ZBI score and the scores of objective and subjective burdens over three time points (before, immediately after, and one month after) (P<0.05). The Bonferroni test revealed the lowest mean score was seen immediately after the intervention and the highest mean score was reported one month after the intervention, indicating the positive effect of the intervention. In contrast, the control group showed no significant difference over three assessment times (P>0. 05).
Conclusion
Although the care burden was relatively high in both groups before the intervention, the coping skills training significantly reduced it in the intervention group. These findings suggest that coping skills training has a significant effect on reducing the care burden of family caregivers of patients undergoing hemodialysis. In this regard, and given the critical role of nurses in providing psychological support, coping skills training should be included in the nursing education programs.
Ethical Considerations
Compliance with ethical guidelines
Ethical approval was obtained from the ethics committee of Birjand University of Medical Sciences (Code: IR.BUMS.REC.1398.332).
Funding
This article was extracted from the master’s thesis of Fatemeh Khaledi, funded by Birjand University of Medical Sciences.
Authors' contributions
Design and writing: Marzieh Mogharab, Fatemeh Khaledi, and Toktam Zia; performing intervention: Fatemeh Khaledi; Data analysis and interpretation: Gholamreza Sharifzadeh .
Conflict of interest
The authors declared no conflict of interest.
Acknowledgments
The authors would like to thank the Deputy for Research of Birjand University of Medical Sciences, all the caregivers participated in the study, and all the staff of the comprehensive treatment center for special diseases in Birjand for their support and cooperation in this research.
References
- Johnson CA, Levey AS, Coresh J, Levin A, Lau J, Eknoyan G. Clinical practice guidelines for chronic kidney disease in adults: Part 1. Definition, disease stages, evaluation, treatment, and risk factors. Am Fam Physician. 2004; 70(5):869-76. [Link]
- Shafipour V, Jafari H, Shafipour L. [The relationship between stress intensity and life quality in hemodialysis patients hospitalized in Sari Iran (2008) (Persian)]. J Sabzevar Univ Med Sci. 2009; 16(3):155-60. [Link]
- Thomas B, Wulf S, Bikbov B, Perico N, Cortinovis M, Courville de Vaccaro K, et al. Maintenance dialysis throughout the world in years 1990 and 2010. J Am Soc Nephrol. 2015; 26(11):2621-33. [DOI:10.1681/ASN.2014101017] [PMID]
- Roberti J, Cummings A, Myall M, Harvey J, Lippiett K, Hunt K, et al. Work of being an adult patient with chronic kidney disease: A systematic review of qualitative studies. BMJ open. 2018; 8(9):e023507. [DOI:10.1136/bmjopen-2018-023507] [PMID]
- Jahanpeyma P, Makhdoomi K, Sajadi SA. The effect of nutrition education program on biochemical parameters among patients with chronic kidney disease undergoing hemodialysis. Crit Care Nurs. 2017; 10(3):e12453. [Link]
- Ghane G, Farahani MA, Seyedfatemi N, Haghani H. The effect of supportive educative program on the quality of life in family caregivers of hemodialysis patients. J Educ Health Promot. 2017; 6:80. [DOI:10.4103/jehp.jehp_78_16] [PMID]
- Sotoudeh R, Pahlavanzadeh S, Alavi M. The effect of a family-based training program on the care burden of family caregivers of patients undergoing hemodialysis. Iran J Nurs Midwifery Res. 2019; 24(2):144-50. [DOI:10.4103/ijnmr.IJNMR_93_18] [PMID]
- Ghane G, Ashghali Farahani M, Seyedfatemi N, Haghani H. Effectiveness of problem-focused coping strategies on the burden on caregivers of hemodialysis patients. Nurs Midwifery Stud. 2016; 5(2):e35594. [DOI:10.17795/nmsjournal35594] [PMID]
- Farzi S, Farzi S, Moladoost A, Ehsani M, Shahriari M, Moieni M. Caring burden and quality of life of family caregivers in patients undergoing hemodialysis: A descriptive-analytic study. Int J Community Based Nurs Midwifery. 2019; 7(2):88-96. [PMID]
- Senmar M, Rafiei H, Yousefi F, Razaghpoor A, Bokharaei M. Caregiver burden among family caregivers of older patients receiving hemodialysis and its relevant factors. J Nephropharmacol. 2019; 8(1):e12. [DOI:10.15171/npj.2019.12]
- Sajadi SA, Ebadi A, Moradian ST. Quality of life among family caregivers of patients on hemodialysis and its relevant factors: A systematic review. Int J community Based Nurs Midwifery. 2017; 5(3):206-18. [PMID]
- Hemmati Maslakpak M, Torabi M, Radfar M, Alinejad V. The effect of psycho-educational intervention on the caregiver burden among caregivers of hemodialysis patients. J Res Dev Nurs Midwifery. 2019; 16(1):13-24. [DOI:10.29252/jgbfnm.16.1.14]
- Anderson RM, Heesterbeek H, Klinkenberg D, Hollingsworth TD. How will country-based mitigation measures influence the course of the COVID-19 epidemic? Lancet. 2020; 395(10228):931-4. [DOI:10.1016/S0140-6736(20)30567-5] [PMID]
- Hoang VL, Green T, Bonner A. Informal caregivers’ experiences of caring for people receiving dialysis: A mixed-methods systematic review. J Ren Care. 2018; 44(2):82-95. [DOI:10.1111/jorc.12235] [PMID]
- Sousa H, Frontini R, Ribeiro O, Paúl C, Costa E, Amado L, et al. Caring for patients with end-stage renal disease during COVID-19 lockdown: What (additional) challenges to family caregivers? Scand J Caring Sci. 2022; 36(1):215-24. [DOI:10.1111/scs.12980] [PMID]
- Xiong F, Tang H, Liu L, Tu C, Tian JB, Lei CT, et al. Clinical characteristics of and medical interventions for COVID-19 in hemodialysis patients in Wuhan, China. J Am Soc Nephrol. 2020; 31(7):1387-97. [DOI:10.1681/ASN.2020030354] [PMID]
- Malo MF, Affdal A, Blum D, Ballesteros F, Beaubien-Souligny W, Caron ML, et al. Lived experiences of patients receiving hemodialysis during the COVID-19 pandemic: A qualitative study from the Quebec renal network. Kidney360. 2022; 3(6):1057-64. [PMID]
- Mosley PE, Moodie R, Dissanayaka N. Caregiver burden in Parkinson Disease: A critical review of recent literature. J Geriatr Psychiatry Neurol. 2017; 30(5):235-52. [PMID]
- Dastyar N, Mashayekhi F, Rafati F. [Caregiving burden in hemodialysis patients’ caregivers in Kerman Province: A descriptive-analytical study (Persian)]. J Jiroft Univ Med Sci. 2020; 7(1): 323-31. [Link]
- Alnazly EK. Burden and depression among Jordanian caregivers of hemodialysis patients: A cross-sectional study. Open Nurs J. 2021; 15(1):29-37. [DOI:10.2174/1874434602115010029]
- Salehi Nejad S, Azami M, Motamedi F, Bahaadinbeigy K, Sedighi B, Shahesmaili A. [The effect of web-based information intervention in caregiving burden in caregivers of patients with dementia (Persian)]. J Health Biomed Inform. 2017; 4(3):181-91. [Link]
- Paschou A, Damigos D, Skapinakis P, Siamopoulos K. The relationship between burden and depression in spouses of chronic kidney disease patients. Depress Res Treat. 2018; 2018:8694168. [DOI:10.1155/2018/8694168] [PMID]
- Gilbertson EL, Krishnasamy R, Foote C, Kennard AL, Jardine MJ, Gray NA. Burden of care and quality of life among caregivers for adults receiving maintenance dialysis: A systematic review. Am J Kidney Dis. 2019; 73(3):332-43. [DOI:10.1053/j.ajkd.2018.09.006] [PMID]
- Lazarus RS, Folkman S. Stress, appraisal, and coping. New York: Springer Publishing Company; 1984. [Link]
- Seyed Tabaee R, Rahmatinejad P, Mohammadi D, Etemad A. [The role of coping strategies and cognitive emotion regulation in well-being of patients with cancer (Persian)]. J Qazvin Univ Med Sci. 2017; 21(2):41-9. [Link]
- Hamadzadeh S, Ezatti ZH, Abedsaeidi ZH, Nasiri N. [Coping styles and self-care behaviors among diabetic patients (Persian)]. Iran J Nurs. 2013; 25(80):24-33. [Link]
- Bayrami M, Mohebbi M. [Relationship between attachment to parents and perception of conflict between parents with social anxiety disorder in female students: The mediating role of emotion-oriented coping strategy (Persian)]. J Clin Psychol. 2016; 8(1):71-82. [DOI:10.22075/JCP.2017.2228]
- Rahimi R, Salimi Bajestani H. [Personality factors and coping strategies based Problem solving and Emotion in men and women with and without type 2 diabetes (Persian)]. J North Khorasan Univ Med Sci. 2017; 9(1):75-88. [DOI:10.18869/acadpub.jnkums.9.1.75]
- Alnazly E. Coping strategies and socio-demographic characteristics among Jordanian caregivers of patients receiving hemodialysis. Saudi J Kidney Dis Transpl. 2016; 27(1):101-6. [DOI:10.4103/1319-2442.174088] [PMID]
- Abbasi A, Ashrafrezaee N, Asayesh H, Shariati A, Rahmani H, Mollaei E, et al. [The relationship between caring burden and coping strategies in hemodialysis patients caregivers (Persian)]. Nurs Midwifery J. 2012; 10(4):532-9. [Link]
- Monteiro AMF, Santos RL, Kimura N, Baptista MAT, Dourado MCN. Coping strategies among caregivers of people with Alzheimer disease: A systematic review. Trends Psychiatry Psychother. 2018; 40(3):258-68. [DOI:10.1590/2237-6089-2017-0065] [PMID]
- Rajabi M, Bastami M, Shahvaroughi Farahani N, Tavanaie AH, Ghanbari B, Alasti H. [Religious coping as a predictor of the burden of care in the caregivers of end-stage cancer patients (Persian)]. Iran J Nurs. 2018; 31(114):6-16. [DOI:10.29252/ijn.31.114.6]
- Ghane G, Ashghali Farahani M, Seyedfatemi N, haghani H. [Effectiveness of supportive educative program on the burden in family caregivers of hemodialysis patients (Persian)]. Nurs Midwifery J. 2017; 14(10):885-95. [Link]
- Maharjan M, Silwal A, Adhikari B, Thapa B, Bhandari B, Shrestha S. Burden and life satisfaction among caregivers of hemodialysis patients residing in Kathmandu. J Karnali Acad Health Sci. 2021; 4(1):1-8. [Link]
- Elkafrawy L, Mounir E, Mohammed Kamal Emad Eldin MK, Abd Elhameed S. Caregiving burden and coping strategies of caregivers caring for elderly with end stage renal disease. Mansoura Nurs J. 2019; 6(2):95-106. [DOI:10.21608/mnj.2019.176370]
- Kazemi A, Azimian J, Mafi M, Allen KA, Motalebi SA. Caregiver burden and coping strategies in caregivers of older patients with stroke. BMC Psychol. 2021; 9(1):51. [DOI:10.1186/s40359-021-00556-z] [PMID]
- Faridah VN, Nursalam N, Agustini NL, Lestari TP, Suratmi S, Juanita F, et al. Determinants of the caregiver burden of ckd patients undergoing hemodialysis. Int J Psychosoc Rehabil. 2020; 24(7):7628-34. [Link]
- Coppetti LC, Girardon-Perlini NMO, Andolhe R, Silva LMCD, Dapper SN, Noro E. Caring ability, burden, stress and coping of family caregivers of people in cancer treatment. Rev Bras Enferm. 2019; 72(6):1541-6. [DOI:10.1590/0034-7167-2018-0605] [PMID]
- Bachner YG. Preliminary assessment of the psychometric properties of the abridged Arabic version of the Zarit Burden Interview among caregivers of cancer patients. Eur J Oncol Nurs. 2013; 17(5):657-60. [DOI:10.1016/j.ejon.2013.06.005] [PMID]
- Talebi M, Mokhtari Lakeh N, Rezasoltani P, Kazemnejad leili E, Shamsizadeh M. Caregiver burden in caregivers of renalf patients under hemodialysis. J Holist Nurs Midwifery. 2016; 26(2):59-68. [Link]
- Zarit SH, Todd PA, Zarit JM. Subjective burdens of husbands and wives as caregivers: A longitudinal study. Alzheimer Dis Assoc Disorders. 1987; 1(2):109-10. [DOI:10.1097/00002093-198701020-00026]
- Ajibade BL, Ajao OO, Fabiyi B, Olabisi OI, Akinpelu AO. Burden experienced by family caregivers of patients with mental disorders at selected hospitals in Ekiti State, Nigeria. International J Health PsycholRes. 2016; 4(2):14-41. [Link]
- Syahri RA, Usma S, Saputra I, Kamil H, Nurjannah N. Caregiver burden associated-risk factor of chronic kidney disease patients with hemodialysis. STRADA J Ilmiah Kesehatan. 2020; 9(2):481-7. [DOI:10.30994/sjik.v9i2.327]
- Jadhav BS, Dhavale HS, Dere SS, Dadarwala DD. Psychiatric morbidity, quality of life and caregiver burden in patients undergoing hemodialysis. Med J Dr. DY Patil Univ. 2014; 7(6):722. [Link]
- Chhetri SK, Baral R. Caregiver burden among caregivers of patient undergoing hemodialysis in tertiary care center: A descriptive cross-sectional study. JNMA J Nepal Med Assoc. 2020; 58(223):148-52. [DOI:10.31729/jnma.4779] [PMID]
- Rezaei H, Niksima SH, Ghanei Gheshlagh R. Burden of Care in Caregivers of Iranian patients with chronic disorders: A systematic review and meta-analysis.Health Qual Life Outcomes. 2020; 18(1):261. [DOI:10.1186/s12955-020-01503-z] [PMID]
- Oyegbile YO, Brysiewicz P. Exploring caregiver burden experienced by family caregivers of patients with End-Stage Renal Disease in Nigeria. Int J Afr Nurs Sci. 2017; 7:136-43. [DOI:10.1016/j.ijans.2017.11.005]
- Menati L, Torabi Y, Andayeshgar B, Khatony A. The relationship between care burden and coping strategies in caregivers of hemodialysis patients in Kermanshah, Iran. Psychol Res Behav Manag. 2020; 13:133-40. [DOI:10.2147/PRBM.S233103] [PMID]
- Sharma M, Lakhara P, Kumar Sharma S, Jelly P, Sharma R. The burden of caregivers of patients undergoing hemodialysis. J Holistic Nurs Midwifery. 2021; 31(2):69-75. [DOI:10.32598/jhnm.31.2.2089]
- Kuture SM. Perceived benefits and burdens encountered by relatives caring for persons on long-term haemodialysis in Johannesburg [PhD dissertation]. 2014. [Link]
- Chen HM, Huang MF, Yeh YC, Huang WH, Chen CS. Effectiveness of coping strategies intervention on caregiver burden among caregivers of elderly patients with dementia. Psychogeriatric. 2015; 15(1):20-5. [DOI:10.1111/psyg.12071] [PMID]
- Narimani D. [Investigating the impact of coping strategies on quality of life and care burden in caregivers of stroke patients in Behbahan Social Security Hospital (Persian)] [MA thesis]. Tehran: University of Welfare and Rehabilitation Sciences; 2013. [Link]
- Brunet HE, Banks SJ, Libera A, Willingham-Jaggers M, Almen RA. Training in improvisation techniques helps reduce caregiver burden and depression: Innovative Practice. Dementia. 2021; 20(1):364-72. [DOI:10.1177/1471301219869122] [PMID]
- Belgacem B, Auclair C, Fedor MC, Brugnon D, Blanquet M, Tournilhac O, et al. A caregiver educational program improves quality of life and burden for cancer patients and their caregivers: A randomised clinical trial. Eur J Oncol Nurs. 2013; 17(6):870-6. [DOI:10.1016/j.ejon.2013.04.006] [PMID]
- Tanrıverdi D, Ekinci M. The effect psychoeducation intervention has on the caregiving burden of caregivers for schizophrenic patients in Turkey. Int J Nurs Pract. 2012; 18(3):281-8. [DOI:10.1111/j.1440-172X.2012.02033.x] [PMID]
- Behzadi H, Borimnejad L, Mardani Hamoleh M, Haghani S. [Evaluating the effect of virtual network-based education on resilience and caregiver burden in parents of children with cancer (Persian)]. Iran J Nurs. 2022; 35(136):118-33. [DOI:10.32598/ijn.35.2.247.4]
- Surani V, Elizadiani Suza D, Tarigan M. The impact of family intervention programs on the caregiver burden of hemodialysis patients. KONTAKT-J Nurs Soc Sci RelatHealth Illn. 2021; 23(2):138-45. [DOI:10.32725/kont.2021.017]
- Chan KY, Yip T, Yap DY, Sham MK, Wong YC, Lau VW, et al. Enhanced psychosocial support for caregiver burden for patients with chronic kidney failure choosing not to be treated by dialysis or transplantation: A pilot randomized controlled trial. Am J Kidney Di. 2016; 67(4):585-92. [DOI:10.1053/j.ajkd.2015.09.021] [PMID]
- Hoseinigolafshani SZ, Taheri S, Mafi M, Mafi MH, Kasirlou L. The effect of group logo therapy on the burden of hemodialysis patients’ caregivers. J Renal Inj Prev. 2020; 9(4):e33. [DOI:10.34172/jrip.2020.33]