Assessment of quality of life for hemodialysis patients in Iraq

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1 International Journal of Environmental Science and Toxicology Research (ISSN: ) Vol. 5(1) pp , February, 2017 Available online Copyright 2017 International Invention Journals Full Length Research Paper Assessment of quality of life for hemodialysis patients in Iraq Gihan Hosny 1 *, Luma A. Kamil 2, Nermin Foda 3 1 Environmental Health Division, Department of Environmental Studies, Institute of Graduate Studies and Research, University of Alexandria, Alexandria, Egypt. 2 Al- Hayat-Center for Dialysis, Al-Karama Teaching Hospital, Baghdad, Iraq. 3 Department of Community Medicine, Faculty of Medicine, University of Alexandria, Egypt. Received 31 January, 2017; Accepted 17 February, 2017 Quality of life, QOL, is an integrated term for assessing the health-related quality of life of certain population. Assessment of quality of life for variable diseases has aided the medical community greatly in understanding this target issue and identifying the functional needs of those patients. The current intervention was conducted to assess QOL for patients undergoing renal dialysis in Baghdad, Iraq, and to investigate the disease variables that make differences in QOL of patients. The WHOQOL-BREF was administered to patients with end-stage renal disease on regular hemodialysis therapy (n=100) in Al- Karama Teaching Hospital, Baghdad, Iraq. Analysis with multiple stepwise regressions was conducted to study determinants of QOL domains and items. Total QOL inhibited by most of the studied patients was fair with the highest scores being for social and environmental domains. Patients older age, female gender, and longer dialysis duration were negative predictors of good QOL. The best QOL was for patients undergoing dialysis three times a week that can be attributed to lower stress due to lower urea level in blood and lack of fatigue, and vice versa. HD patients who had been on long term treatment, showed poorer QOL which could be argued that those patients experienced significant QOL changes over time, including deterioration in physical, social and environmental well-being as well as in overall mental health. The results of multiple linear regression for different variables of QOL demonstrated that the only significant predictors were age, sex, environmental exposures, frequency and duration of dialysis. Different factors like educational levels, marital status, vocational involvement, socioeconomic status, residence of rural area, distance covered to reach hospital, mode of transport, total time consumed in getting HD significantly affect QOL of HD patient but are not predictors for QOL of the studied patients. The concept of quality of life will stimulate further research into this difficult area, and many indicators are intertwined that affect person s overall QOL. Indicators based solely on certain characteristics of the patients should be managed as they may pose serious restrictions to the measure of QOL. Ultimately, this may limit the predictive power of QOL. Keywords: Hemodialysis, QOL, WHOQOL, Quality of life. INTRODUCTION The concept of Health-related quality of life, HRQOL, and its determinants have evolved since the 1980s to encompass those aspects of overall quality of life that *Correspondence Author gihan1hosny@gmail.com; hosny_gihan@yahoo.com; Tel: (+203) can be clearly shown to affect health; either physical or mental. HRQOL is a multi-dimensional concept that includes domains related to physical, mental, emotional and social functioning. It goes beyond direct measures of population health, life expectancy and causes of death, and focuses on the impact health status has on quality of life (Selim et al., 2009; The WHOQOL Group, 1995; Fayers and Machin, 2016; Koller and Lorenz,

2 Hosny et al ). HRQOL refers to the physical, psychological and social domains of health that are unique to each individual. Each of these domains can be measured by the objective assessments of functioning or health status and the subjective perceptions of health (Fayers and Machin, 2016; Koller and Lorenz, 2002). Hemodialysis is a treatment option available for patients experiencing renal insufficiency, in which a machine is used to act out the function of the kidney such as filtering the blood and excretion of by-products. Considering the risks that may occur with the treatment options available, many choose to be placed on dialysis. However, hemodialysis treatment may be debilitating. Patients with renal failure face many challenges due to their condition which may leave them feeling fatigued and depressed. Body image may be affected by fistula or grafting for dialysis access. Finances may be affected by the high cost of weekly treatments for dialysis and occasional admission to the emergency department due to complications (Mapes et al., 2003). Over the past few decades, quality of life research endpoints has emerged as valuable research tools for assessing the outcome of therapeutic intervention in chronic diseases (Kaufman, 2001). End-stage renal disease, ESRD, is a chronic disease causing a high level of disability in different domains of the patients' lives, leading to impaired QOL. The availability of various renal replacement therapies (RRT) has reduced the severity of symptoms and resulted in longer survival of ESRD patients. Hemodialysis therapy is time-intensive, expensive, and requires fluid and dietary restrictions. Long-term dialysis therapy itself often results in a loss of freedom, dependence on caregivers, disruption of marital, family, and social life, and reduced or loss of financial income (Hudson and Johnson, 2004, Blake et al., 2000). Hemodialysis alters the life style of the patient and family and interferes with their lives. The major areas of life affected by ESRD and its treatment includes employment, eating habits, vacation activities, sense of security, self-esteem, social relationships, and the ability to enjoy life. Due to these reasons, the physical, psychological, socioeconomic, and environmental aspects of life are negatively affected, leading to compromised QOL (Lopes et al., 2003). Survival of ESRD patients has been largely improved because of medical progress, advanced technology, and better patient care. Accumulated data in the recent decade show that health-related quality of life markedly influences dialysis outcomes. Attention thus needs to be focused not only on how long but also on how well ESRD patients live (Molsted et al., 2004). Compared with the general population, ESRD patients treated with hemodialysis have significantly impaired HRQOL (Mapes et al., 2004). Evaluation of HRQOL in patients with chronic diseases is becoming very important. HRQOL assessment helps to plan the individual strategy of treatment, to determine the efficacy of medical intervention, and to evaluate the quality of medical care. In comparison with HRQOL of the general population, it provides the opportunity to evaluate the psychological burden of chronic disease, and the effect of specific treatment (Kalantar-Zadeh and Unruh, 2005). Several authors have suggested that HRQOL assessment is essential to evaluate quality and effectiveness of ESRD patient care, comparing alternative treatments and RRT modalities, improving clinical outcomes, facilitating complex rehabilitation of ESRD patients, and enhancing patient satisfaction (Vos et al., 2006; Mau et al., 2008). Regular HRQOL monitoring was suggested to become part of regular ESRD patient assessment and incorporated into the continuous quality assurance and quality improvement systems (Kalantar-Zadeh and Unruh, 2005; Unruh et al., 2005). The underlying study was untaken as a pioneer study in Baghdad, Iraq, to assess the quality of life for patients undergoing renal dialysis. To achieve such a goal, the current status for addressing various factors that may contribute to high incidence of renal dialysis in Baghdad was investigated. Type of dialysis treatment and different disease predictors that can make a difference to the quality of life of renal patients was identified. The study was undertaken to target evaluation of QOL for hemodialysis outpatients at Al- Hayat-Center, Baghdad. MATERIALS AND METHODS Study design The current multicenter, randomized controlled trial has been performed at Al-Hayat Center, HC, for hemodialysis, Al-Karama Teaching Hospital, Baghdad, Iraq. HC is a very important governmental center that covers different localities in Iraq and can receive up to 200 HD patients daily. Data collection was started from October 2015 for eight months. Study setting The study was undertaken to target evaluation of QOL for hemodialysis outpatients at Al-Hayat Center. The selected patients were chosen randomly who accepted to participate in this study, considering the constraints of accessibility. Different administrative affiliations were filled out and submitted to perform the study, directed to Directorate of Health Affairs, Baghdad, Ministry of Health and Population; and Al- Hayat-Center for hemodialysis, Al-Karama Teaching Hospital (KTH).

3 12 Int. J. Environ. Sci. Toxic. Res. Study sample The study sample constituted a hundred patients with ESRD on regular hemodialysis, who accepted to participate in the study. Patients undergo HD on regular basis between 3 months and 5 years were included in the study. A sample size of 100 HD patients was chosen randomly from 400 patients treated during the study time in the mentioned center. The sample was selected to be efficiently and conveniently represented to the underlying study in order to estimate an average rate of QOL among HD patients (25% of total patients). All patients were under the same kind of treatment including hemodialysis and/or medications to unify the criteria and compatibility for the study. The only inclusion criterion was the duration after commencing hemodialysis regimen. Patients on regular hemodialysis of fewer than three months duration were excluded from the study, consequently, patients with acute renal failure were also excluded. Study tools Because of their health status, each patient was interviewed to accomplish the following questionnaires: The WHOQOL-BREF and general health status questionnaire. The WHOQOL-BREF The WHOQOL-BREF, Arabic version, was used to assess the patients perception for their QOL. The WHOQOL-BREF consisted of 2 global items, G1 for overall QOL and G2 for general health, and 26 items in the physical, psychological, social relations, and environment domains (Szabo, 1996; The WHOQOL Group, 1995; 1998; Skevington et al., 2004; Valderrabano et al., 2001). Application method, reference time point, and item scoring were performed as described for the original WHOQOL-BREF (Edgell et al., 1996). Global QOL score was calculated as the arithmetic mean of G1 and G2. Item scores ranged from 1 to 5, and domain scores, from 4 to 20, both on a Likert scale. General health status questionnaire General health status questionnaire was self-constructed to assess the health status of the studied sample. The first section was designed to assess the demographic criteria of the patients, including age, gender, address, marital status, education, occupation, and socioeconomic status (using a brief socio-economic scale). The second section was designed to examine different factors that may contribute to renal failure, including; occupational exposures, duration of working, residence adjacent to pollution source, the source of drinking water, concomitant diseases, and the presence of congenital disorders ended up by renal failure. The third section was designed to obtain information on dialysis including; onset of renal failure, type of dialysis, time of starting dialysis, the frequency of dialysis, and treatment side effects. Medical records of patients were obtained from the medical center to get data on liver and kidney functions, concomitant diseases, and blood picture. Validation Analysis After data were collected it was revised, coded and fed to statistical software IBM SPSS version 20, for assessing reliability and validity in 100 HD patients living in Iraq. Reliability assessments included Cronbach s test for reliability. Validation assessments included content validity, criterion-related validity, concurrent validity, exploratory factor analysis, and confirmatory factor analysis of construct validity. The comparative fit index and non normed fit index were calculated to test goodness of fit for confirmatory factor analysis. Permission and official consents For accomplishing the underlying study, official permission was obtained from Research Ethical Committee, Al-Hayat Center for hemodialysis, Al- Karama Teaching Hospital, Baghdad, Iraq. Official consent was utilized from Institute of Graduate Studies and Research, University of Alexandria, to facilitate performing the study and indicate the lack of conflict of interest to any subscribed organizations or hospitals. Verbal consent was obtained from each participated patients to be involved in this study. Data collection The WHOQOL-BREF and general health status questionnaires were used for data collection. Site visits and key informant interviews with patients or their families were employed by the researcher to collect information regarding various aspects of QOL of HD patients participated in the study. Ethical clearance An oral consent was obtained from participants at the beginning of data collection after explaining the study

4 Hosny et al. 13 objectives and assuring data confidentiality. Everyone was given the right to withdraw from the research at any time. Statistical analysis After data were collected, it was revised, coded and fed to statistical software IBM SPSS version 20. The given graphs were constructed using Microsoft excel software. All statistical analysis was done using two-tailed tests and an alpha error of P value less than or equal to 0.05 was considered to be statistically significant. Regarding scoring system, the items discrete scores for each QOL domain were summed together then the sum of scores for each domain and the total score was calculated by summing the scores given for its responses. All scores were transformed into score % as follow: Score % = (the observed score / the maximum score) x 100. Then score % was transferred into categories for QOL as follow: Poor: Score % < 50%; Fair : Score % 50- <75%; Good: Score % 75%. Analysis of numeric data was performed utilizing onesample Kolmogorov-Smirnov test, independent sample t- test, one-way ANOVA and correlation analysis. Multiple Linear Regression Model Linear regression was used to predict a dependent variable (QOL) on the basis of continuous and/or categorical independents (sample characteristics; age, sex, occupation, marital status, frequency and onset of dialysis etc.) and to determine the effect size of the independent variables on the dependent; to rank the relative importance of independents and to understand the impact of covariate control variables. The impact of predictor variables is usually explained in terms of regression coefficient (B) which mean the amount of increased risk at the exposed groups relative to the reference one keeping all other variables constant. questionnaire items, 0.79, 0.83, 0.80, 0.92 and 0.92 for physical, psychological, social, environmental, and total QOL questionnaire items, respectively. As shown in Table 1, the total QOL reliability showed a coefficient of 0.92 and a convergent validity of Each domain showed low correlation with other domains, indicating that they can measure the instituted target independently. Considering discriminate validity (which means items measuring different topics are uncorrelated with each other s) all domains show low correlation with other domains with correlation coefficient ranged from 0.02 for global QOL to 0.31 for physical QOL, 0.28 for psychological QOL, 0.07 for environmental QOL, and 0.19 for social QOL with an overall discriminate validity of 0.14 (excellent). Assessment of QOL among patients Table 2 illustrates descriptive statistics in the form of minimum and maximum scores with mean and standard deviation for overall domains indicated in WHOQOL BREF. The WHOQOL-BREF consisted of 2 global items, G1 for overall QOL and G2 for general health, and 26 items in the physical, psychological, social relations, and environment domains. The score range describes the scale of categorical data for each domain as follows; global QOL (2-10); overall QOL (1-5); general QOL (1-5); physical QOL (13-40); psychological QOL (6-30); social QOL(5-15); environment QOL (12-27) and total QOL score (51-117), respectively. The mean score values for each domain were as follows; global QOL (6.4±4.4); overall QOL (3.3±1.5); general QOL (3.1±1.5); physical QOL (25±6.2); psychological QOL (16.8±5.9); social QOL ( ); environment QOL ( ) and total QOL score (80.2±15.4), respectively. Results showed QOL scores were the highest for social domain, followed by environmental, while the least score was noticed in physical and psychological domains. Table 2 illustrates mean and standard deviation for each question of the 26 questions of WHOQOL BREF among the studied hundred patients. RESULTS Reliability Internal consistency, reliability and validity of the WHOQOL-BREF to assess QOL of patients at Al-Hayat- Center for hemodialysis, Baghdad, Iraq were verified, as illustrated in Table 1. The WHOQOL-BREF was proven to be reliable and valid among patients, as indicated by the high coefficient values. Using alpha Cronbach s test for calculation of reliability coefficient showed highly correlated values. It was 0.96 for global health Total QOL grade analysis Total QOL grade analysis among the studied hundred patients undergoing hemodialysis is shown in Table 3. As illustrated score percentage was considered as poor if it is 50%; fair if it is ranged from 50% to 75%; and good if it is 75%. Total QOL grade among the participated sample of patients was poor among 18%, fair among 66%, and good among 16%. Results indicated that the total QOL inhibited by most of the studied patients was fair.

5 14 Int. J. Environ. Sci. Toxic. Res. Table 1. Internal consistency of WHOQOL BREF domains for the targeted patients. Reliability coefficient (alpha Cronbach's) Convergent validity Discriminate validity Global QOL (2-10) Overall QOL (1-5) General QOL (1-5) Physical QOL (9-45) Psychological QOL (6-30) Social QOL (3-15) Environmental QOL (6-30) Total QOL score (26-130) Table 2. Assessment of QOL scores among patients. Minimum Maximum Mean SD Global QOL (2-10) Overall QOL (1-5) General QOL (1-5) Physical QOL (9-45) Psychological QOL (6-30) Social QOL (3-15) * 2.0 Environment. QOL (6-30) * 3.4 Total QOL score (26-130) Table 3. Descriptive analysis of total QOL grade among patients. Total QOL grade No % Poor Fair Good Poor score% <50%; Fair score% 50%-<75%; Good score% 75%; No, number of patients; %, percentage. Assessment of total QOL with different studied factors Table 4 shows assessment of total QOL scores with socio-demographic criteria of patients including; age, gender, education, occupation and socio-economic status. Age groups of <30, 30-, 40, 50-, and 60+ years old reported mean values of 81.3±16, 82.2±12.4, 85.2±16.1, 78.1±14.1, and 77.7±16.2, respectively. The quality of life was the worst in the elderly patients above sixty or fifty years old. Analysis revealed no statistical significant differences between total QOL among the five patient age groups, using one-way ANOVA at P The total QOL for male patients was 84.6±14.7 and for female patients was 71.2±12.9. Statistical significant differences were detected between the total QOL of the two genders of patients, using independent sample t-test at P QOL was better among males compared to females, which may be attributed to the differences in pain threshold, sensitivity, and tolerance. Total QOL of patients was 69.8±13.4 for none educated, 80.3±16.3 for elementary educated, 80.1±15.3 for secondary educated, 102.5±0.7 for university educated, 83.3±14.1 for post-graduated. Statistical significant differences between total QOL with different levels of education of patients were detected, using one-way ANOVA at P Total QOL increased for a high level of education and decreased for a lower level of education of the patient, showing the worst QOL for none educated patients. Results indicate that level of education plays an important role in getting better QOL. The total QOL of patients was assessed with different marital status. QOL was the worst among widows (71.1±9.7) followed by divorced (73.0 ± 20.0) and single (79.5±19.3), while the highest scores for QOL were detected among married patients (81.4±15.0). However, no statistical significant differences were detected between groups, using oneway ANOVA at P The results show that marital status gives patients more support to enhance their QOL. Total QOL scores were assessed with the different

6 Hosny et al. 15 Table 4. Assessment of total QOL for patients undergoing hemodialysis with socio-demographic criteria. Socio demographic data Total QOL score F (P) Mean SD Age (years) 0.91 (0.464) < Gender t=8.2 (0.001)* Male Female Education 3.1 (0.021)* None Elementary Secondary University Post-graduate Marital status 1.3 (0.285) Single Married Divorced Widow Occupation 3.7 (0.001)* Not working Professional Trader Employee Handcraft Free works Retired Student Socio-economic status 3.5 (0.041)* Low Moderate High F; One-way ANOVA t; independent sample t-test P 0.05 professional activities. High scores were calculated for professionals, employees, and private workers, as follows: 84.8 ±19.1, 86.9±13.3, 86.7±14.8, respectively. Fair scores were detected for hand craft work (70.6±11.7), retired (76.2±11.4) and traders (73.0±0.0), while the worst QOL was detected among none working patients (69.7±13.0) and students (69.5±2.1). Analysis revealed statistical significant differences between total QOL and different classes of working status using oneway ANOVA at P It seems that working status can modulate patients QOL with highest QOL for professionals, employees and private workers in contrast to none workers. Patients with low socio-economic status had scores of 75.7±14.6, moderate socioeconomic status had scores of 79.1±15.2 and high socio-economic status had scores of 85.3±15.6. Statistical significant differences were detected between total QOL and socio-economic status of patients undergoing hemodialysis. The best QOL were noticed in patients who have high socio-economic status and worse QOL in patients who have low socio-economic status, indicating that socio-economic status plays an important role in grading of QOL for patients. Assessment of total QOL with different variables related to disease Table 5 shows the total QOL scores with different variables related to the disease that may contribute to further stress on patients and can affect total QOL of the studied patients. Variables included frequency, duration, complications, and congenital causes of dialysis. There were statistical significant differences between total QOL

7 16 Int. J. Environ. Sci. Toxic. Res. Table 5. Total QOL for patients undergoing HD with different variables related to disease. Dialysis and Medical data Total QOL score F (P) Mean SD Dialysis times/ week 3.1 (0.045)* Once Twice Three times Dialysis duration (years) 2.9 (0.047*) < 1 year > Dialysis complications 1.3 (0.261) None Anemia Hypertension Hypotension Brain stroke Retinal damage Cardiac Cataract HBV HCV HTN/kidney abnormality PSGN/arthrodesis Congenital conditions t=1.4 No (0.118) Yes F: One Way ANOVA t: independent samples t-test * P 0.05 (significant) for patients with a different frequency of dialysis per week, using one-way ANOVA at P The worse QOL was noticed in patients undergoing hemodialysis once a week (66.6±14.4) while the best was for patients undergoing hemodialysis three times a week (82.1±14.2), followed by those undergoing it twice a week (78.2±17.2). The probable cause for having best QOL for patients undergoing dialysis three times a week can be attributed to lower stress due to lower urea level in blood and lack of fatigue, and vice versa for other groups. The total QOL for patients undergoing hemodialysis is getting worse over time of long-term treatment, as illustrated in Figure 1. The short duration of dialysis retained good QOL for patients and vice versa. Patients undergoing HD duration for a period less than one year, from 1-2 years, from 3-5 years, and more than 5 years, inhibited total QOL of (86.4±11.4), (84.9±11.7), (76.1±18.7), and (65.4±12.9), respectively. Analysis revealed statistical significant differences between HD duration groups in total QOL for patients, using one-way ANOVA at P The longer the duration of treatment is, the poorer the QOL. Deterioration in quality of life is particularly evident in the HD group of patients who have been on dialysis for an extended period of time. Most qualities of life domains seems to be affected, including overall mental health. After taking into consideration that QOL deficits were mostly indicated by HD patients who had been on long-term treatment, it could be argued that these patients experienced significant QOL changes over time, including deterioration in physical, social and environmental well-being as well as in overall mental health. There were no statistical significant differences between total QOL of patients and dialysis complications, using one-way ANOVA at P The best QOL life was detected in patients having hypotension, as a complication, (86.0±12.7) while the worse was detected in patients having HBV (59.0±0.0). No statistical significant differences were detected between total QOL and the presence of congenital disorder as a possible cause of renal failure, using t-test at P In absence of a congenital condition, patients encountered better QOL (81.5±16.1), in contrast to patients who had congenital disorders related to disease incidence (75.6±12.2). Multiple linear regression for predictors of QOL Linear regression can be used to predict a dependent variable (QOL) on the basis of continuous and/or

8 Hosny et al. 17 Figure 1. Scatter plot for relation between total QOL scores and dialysis duration in years. Table 6. Multiple linear regression for predictors of QOL of the studied patients undergoing hemodialysis. Predictor Unstandardized SE Standardized T Sig. Coefficients (St. error) Coefficients (Constant) Age * Sex * Education Socio-economic status Exposure * Nature of drinking water Daily water quantity/ L Dialysis times/ week * Dialysis duration (years) * Dialysis complications Congenital disorders Model significance F=3.4; P=0.001* Adjusted R categorical independents (Sample characteristics) and to determine the effect size of the independent variables on the dependent; to rank the relative importance of independents and to understand the impact of covariate control variables. The impact of predictor variables is usually explained in terms of regression coefficient (B), which means the amount of increased risk at the exposed groups relative to the reference one keeping all other variables constant. Table 6 shows the multiple linear regression for predictors of QOL of patients undergoing HD in Baghdad, Iraq. A multiple linear regression model was constructed by using summary scores of each facet/item and domain as dependent variables. Age, gender,

9 18 Int. J. Environ. Sci. Toxic. Res. education, socioeconomic status, exposure, nature, and quantity of drinking water, dialysis time and duration, and congenital conditions were adopted as independent variables and controlled in this regression model. The adopted selection and exclusion criterion was p less than Significant associations were extracted with many items of patients, including; age, sex, environmental exposures, frequency and duration of dialysis, using model significance of F=3.4 and P= Significant association of age indicated that the more the age is, the poorer is the QOL for a patient, and vice versa. The same was noted for gender as males had better scores of QOL than females, which can be attributed to higher pain threshold among males. Other variables including education, socioeconomic status, nature and daily quantity of the drinking water, dialysis complications and congenital conditions showed no significant association with overall assessed QOL. However frequency and duration of dialysis showed strong association with a better QOL for patients undergo more frequent dialysis per week (three times a week) or had shorter duration (in years) for treatment. The results of multiple linear regression analysis for scores of QOL demonstrated that the only significant predictors are age, sex, environmental exposures, frequency and duration of dialysis. DISCUSSION Studies on the QOL of patients with chronic disease have increased these days. It has become an integral parameter to assess patient satisfaction and improvement with therapy. Improvement in the QOL has become the major treatment goal in ESRD patients. Because ESRD patients have several other comorbidities such as hypertension, diabetes, anemia, etc., they have to take different medications. These may have significant adverse effects and may be associated with drug interactions. Moreover, the patients are prone to non-compliance and all these will affect the QOL of the patients (Joshi, 2014; Gudex, 1995; Mollaoglu, 2013; Noshad et al., 2009). The way each patient lives and relates to chronic renal disease is personal and unique, since it depends on many factors, such as: psychological profile, social and environmental conditions and family support. QOL perceptions influence the way each individual faces the disease; positive perceptions are related to rational strategies, like setting a goal or knowing more about the condition; negative ones relate to denying the situation, acting as if it were not real (Gudex, 1995). The QOL can be measured from different angles, sometimes using generic instruments, in some cases disease-specific instruments, or measuring physical and laboratory parameters. It is very essential to measure the psychological domain, as the patient may experience depression or anxiety. That is the reason for selecting WHOQOL-BREF where psychological and spiritual domains were included in the assessment. The studies were mainly concentrated on the physical, psychological, social and environmental domains of the patient and how it affects the overall QOL of ESRD patients undergoing HD (The WHOQOL Group, 1998; Skevington et al., 2004). Age as a predictor for QOL The current study was performed on renal failure patients with ages ranged from 17 to 89 years old and a mean age 52.1 years. The mean HRQOL scores were relatively higher in younger age groups in all domains, with no statistical significant differences but showed a strong association with multiple regression analysis. The association of age with HRQOL is quite complex and illustrates the complexity of the QOL concept (Bayoumi et al., 2013). Some studies conducted in different countries also demonstrated that age was strongly inversely associated with the physical domain scores. As age increases, physical function of the body decreases among elderly (Bayoumi et al., 2013; Stojanovic and Stefanovic, 2007; Anees et al., 2014; Abdel-Kader et al., 2009; Unruh et al., 2008). A recent Saudi research showed that age was a negative predictor of HRQOL score (Bayoumi et al., 2013). Results are in agreement with the current results. According to Liu et al. 2006, age above forty years was a significant risk factor for QOL of HD patients. Gender as a predictor for QOL Gender affects QOL in general population and HD patients as well. Females have poor QOL as compared to male patients. The current study revealed that males have better total QOL and in particular social relationship domain as compared to females. The reason of better QOL in males compared to females is that males have better social relationships (strong relation and sexual activation) and support than females (Santos et al., 2009; Mujais et al., 2009; Ferreira et al., 2011). Male patients have more chances of outing and meeting friends which give them encouragement to face challenges of life, a similar observation was made by Santos et al. 2009, Mujais et al Lower scores in QOL domains among females compared to males were significantly noticed. The majority of female patients felt that they were a burden to their families and

10 Hosny et al. 19 were apprehensive about their bodily image and appearance. This might have contributed to the lower QOL scores in female ESRD subjects. Other investigators have also reported lower health-related QOL in women than in men (Ferreira et al., 2011). However, the exact cause for lower QOL in female ESRD patients is not clear. But it is possible that factors such as biological, psychological, social and/or cultural factors may be involved. Also, biases in the provision of care or differences in physicians' attitude towards female patients might have contributed to the lower QOL scores (Santos et al., 2009, Mujais et al., 2009). In the current study, old age, female gender, poor education and comorbid conditions have a negative impact on the QOL of HD patients in Iraq. These findings indicate a general need for social support for female patients on HD and early diagnosis and management of comorbid conditions (Ferreira et al., 2011, Coelho-Marques et al., 2006). Marital status as a predictor for QOL In our study, marital status was not significantly associated with QOL scores. This finding is in disagreement with Sagduyu et al. 2006, who reported a significant effect of marital status on KDQOL. The difference could be attributed to the nature of the oriental families in general, and the Iraqis families in particular, which is usually extended to close relations. Therefore, unmarried patients would not feel lonely or helpless. Marital status affects QOL, the major reason behind this can be summarized as unmarried persons are dependent on their families as compared to married persons who have to run the whole family which increases the financial stress and finally affect QOL (Kimmel, 2000). Stressful factors, which increase patients depression levels and gather physiological and psychological aspects during treatment, can impair QOL. The change in patients QOL, just like the disease and its treatment, can cause symptoms that radically change the complete functioning of individuals (Ferreira et al., 2011). Social support as a predictor for QOL Social support when received from friends, can aid in positive contribution to decrease patients depressive mood, and such a support may in turn have impacts on differences in mortality rates, once it is in adhesion to treatment. Studies on chronic renal failure showed that social support plays an important role against negative effects of stressful situations (Ferreira et al., 2011; Coelho-Marques et al., 2006). It was also shown that better quality of life in patients who had good relations with the medical-nursing staff. Indeed, a stable and sincere relation is a valuable tool for both sides. A good relationship may also reflect that medical team knows to reduce the patient s stress using the supportive techniques or proper intervention methods. The situation can be beneficial to both the patient and the healthcare professional through the knowledge gained. This study provides healthcare providers with ways to identify the patient s QOL. It can also be a tool for educating patients by increasing their awareness that may affect and improve their QOL (Chiang et al., 2004). Education as a predictor for QOL There is a positive relationship between levels of education and QOL (Chiang et al., 2004). In the current study, statistical significant differences were detected between total QOL with different levels of education of patients, using one-way ANOVA at P 0.05, but education was not a predictor of QOL in multiple regression analysis. Better QOL was detected in educated patients compared to illiterate. It can be explained that educated patients have better understanding of the disease and better awareness of its treatment options. Patients, who were satisfied with treatment and accepted it, had better working capability and could sleep and rest better which improved their QOL. The level of school education was associated with dimensions of WHOQOL-BREF. Subjects with higher education reported significantly higher QOL scores. The results of our study are consistent with findings of previous studies that reported a positive relationship between the level of school education and QOL (Patti et al., 2007; Coelho-Marques et al., 2006). A higher school education is known to play an essential role in raising the awareness of chronic diseases and in a better coping ability with them. Socio-economic status as a predictor for QOL The role of higher income is reflected in higher scores in all domains of QOL, the current results are inconsistent with findings of other studies that reported a positive association between family income and QOL scores (Patti et al., 2007, Coelho-Marques et al., 2006). The higher the income of an individual, the better the QOL, as it improves the ability of the patient to afford the required treatment and ensures a better QOL. A secure income is a reassurance to patients that contributes to their psychological wellbeing. Financial difficulties due to premature retirement or loss of employment due to the disease may result in deterioration of QOL.

11 20 Int. J. Environ. Sci. Toxic. Res. Working status as a predictor for QOL Improvement in education and job opportunities are important factors in improving financial status and QOL in HD patients (Patti et al., 2007, Coelho-Marques et al., 2006, Bohlke et al., 2008). Same observation was made by Patti et al., 2007, who reported that employment is a vital factor for improving QOL of ESRD patients. In this study, only 37% of patients were unemployed and almost two-thirds of sample was employed. According to Sathvik et al., 2008, employment can affect three domains of QOL. Patients who are employed have better QOL in physical, psychological, health and social relationship domains than unemployed patients. patients on long term dialysis appear to be more seriously compromised in their quality of life and mental health. The finding of increased duration of dialysis and reduction of quality of life is consistent with results of Seica et al From the current study, it can be concluded that HD patients had QOL scores that fall in the middle of the scale, with the highest being for environmental and physical domains. Patients older age, female gender, and less frequent and longer duration of dialysis were negative predictors of QOL scores, the findings are in consistency with previous studies. The important finding from the current study is that the WHOQOL-BREF, Arabic version, is valid for HD patients of Iraq. Dialysis frequency and duration as predictors for QOL Dialysis usually constitutes a burden on patients. It was discussed that time consumed in getting HD affects QOL, perhaps underlying factor is distance covered to reach the hospital and private transportation (Kutner, 2001). In this study, statistical significant differences were detected between dialysis frequency per week and QOL and QOL increased in patients undergoing HD three times a week compared with twice or once a week. These results can be explained by the findings of a previous study which reported that hemodialysis is effective in urea clearance and made the patients feel comfortable (Manandhar et al., 2009). Deterioration in QOL is particularly evident in HD patients who have been on dialysis for an extended period of time. Most QOL domains seem to be affected, including overall mental health. After taking into consideration that QOL deficits were mostly indicated by HD patients who had been on long term treatment, it could be argued that these patients experienced significant QOL changes over time, including deterioration in physical, social and environmental wellbeing as well as in overall mental health. In the relevant literature, it has been suggested that health-related QOL was more compromised in HD patients, which may only become evident as time on therapy increases (Ginieri- Coccossis et al., 2008; Seica et al., 2009). The results of the current study provided evidence that the HD on long term duration of treatment had increased deficits in physical, social and environmental QOL, as well as in mental health. Further, patients who had similar length of current treatment in the hemodialysis center differ only with regards to their environmental well-being. Thus, in relation to differences between patients in early and later years of treatment, it appears that QOL deficits in HD patients become more extended over time, and seem to be more precisely signified by the factors in the environmental QOL domains. It may be argued that HD CONCLUSION The current study leads us to three conclusions: (1) the WHOQOL-BREF is valid for HD patients in Iraq; (2) HD has a negative impact on many QOL measures with various degrees, especially in patients with more severe disease; and (3) Problems of HD patients were prominent and clinically manageable determinants of QOL in HD patients. The concept of quality of life will stimulate further research into this difficult area, and many indicators are intertwined that affect person s overall QOL. The challenge for the next decade will be to continue to design a QOL instrument that takes both disease specific and culture specific subjective and objective factors into account so that it would be possible to get the complete assessment of QOL of end-stage renal disease patients. 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