Back to Journals » International Journal of Nephrology and Renovascular Disease » Volume 13

Psychosocial, Spiritual, and Biomedical Predictors of Hope in Hemodialysis Patients

Authors Rambod M , Pasyar N, Mokhtarizadeh M

Received 22 March 2020

Accepted for publication 28 May 2020

Published 26 June 2020 Volume 2020:13 Pages 163—169

DOI https://doi.org/10.2147/IJNRD.S255045

Checked for plagiarism Yes

Review by Single anonymous peer review

Peer reviewer comments 2

Editor who approved publication: Professor Pravin Singhal



Masoume Rambod,1,2 Nilofar Pasyar,1,2 Mahsa Mokhtarizadeh3

1Community Based Psychiatric Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; 2School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran; 3Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran

Correspondence: Nilofar Pasyar Email [email protected]

Background: Hemodialysis patients deal with some psychological and social problems. These problems may be the predictors of hope. This study aimed to determine the psychosocial, spiritual, and biomedical predictors of hope in hemodialysis patients.
Methods: This cross-sectional study was conducted on 350 hemodialysis patients in hemodialysis centers affiliated to Shiraz University of Medical Sciences. Adult Hope Scale, Depression Anxiety Stress Scales, Personal Resources Questionnaire-85, Spiritual Well-Being Scale, and biomedical markers were used for data collection. The data were entered into the SPSS 22 software and were analyzed using Pearson’s correlation coefficient and linear regression analysis.
Results: The mean score of hope was 28.54 (SD=5.27). The mean scores of depression, anxiety, and stress were 17.87 (SD=7.62), 13.12 (SD=3.47), and 12.99 (SD=3.88), respectively. The mean scores of social support and spiritual well-being were 126.35 (SD=17.53) and 74.02 (SD=5.84), respectively. The means of biomedical markers including interdialytic weight gain, urea nitrogen, creatinine, phosphate, sodium, and potassium were 2.10 (SD=1.04), 51.55 (SD=13.10), 6.98 (SD=2.48), 4.71 (SD=1.08), 139.32 (SD=4.91), and 4.87 (SD=0.93), respectively. The results revealed a significant association between hope and depression, anxiety, stress, social support, and spiritual well-being (p< 0.05). In addition, stress (β=− 0.14, p=0.01), anxiety (β=− 0.20, p=0.002), and social support (β=0.49, p< 0.001) were the predictors of hope.
Conclusion: The hemodialysis patients reported moderate levels of hope, social support, anxiety, and depression. In addition, most of them adhered to dietary and fluid restrictions. Considering the association between hope and social support, spiritual well-being, anxiety, depression, and stress, using some interventions regarding the mentioned variables might increase hope among hemodialysis patients.

Keywords: hemodialysis, hope, anxiety, depression, spirituality, social support

Introduction

Chronic renal failure is one of the major public health issues in the world. End-Stage Renal Disease (ESRD) is a stage of chronic renal failure that results in mortality without renal replacement therapy.1 Renal replacement therapy consists of dialysis and kidney transplant. There are two types of dialysis, namely peritoneal dialysis and hemodialysis. In hemodialysis, a machine is used to filter waste from blood. In 2015, hemodialysis costed 62 million US dollars.2 It has been estimated that there are 4.90–7.08 million ESRD patients globally.3

It was reported that hemodialysis patients had a lower quality of life compared to those who underwent renal transplantation.4 In another study on hemodialysis patients, health/functioning and socioeconomic subscales of quality of life were lower compared to psychological/spiritual and familial subscales.5 Hemodialysis patients might also have higher levels of biomedical markers, such as phosphate, potassium (K), and urea nitrogen (BUN).6 Moreover, some studies indicated that hemodialysis patients suffered from psychological issues; approximately 70.5% of them had low levels of depression and 64% reported low levels of anxiety.7

Social support has been reported to be one of the factors that might play an important role during ESRD and protect hemodialysis patients from depression.8 In fact, ESRD and hemodialysis-related changes increased the patients’ dependence on others, reduced their self-esteem and loneliness, and increased their need for social support.9 A prior study showed that social support was associated with quality of life in hemodialysis patients.5 It has also been mentioned that social support increased adherence10 and reduced depression in hemodialysis patients.11 Peer support decreased anxiety, depression, and stress in hemodialysis patients, as well.12

Along with social support, religion and spirituality also impacted individuals’ lives and promoted their life quality.13 Spirituality was effective in improvement of physical, mental, and social health in chronic diseases.14 Higher levels of spirituality also led to well-being and moral development.15 Furthermore, hope was associated with spiritual beliefs and optimism.16 Hope predicted physical, psychological, social relationships and environmental domains of quality of life in hemodialysis patients.17 In the same vein, hope predicted physical activity, disease threat appraisal, and all aspects of quality of life including physical, functional, emotional, and social well-being in chronic diseases such as cancer.18 On the other hand, pain, depression, self-esteem, and functional status were found to be the predictors of hope in cancer patients.19 Another study demonstrated that anxiety, depression, effects and symptoms of renal disease, and mental health dimension of quality of life were the predictors of hope in hemodialysis patients.20

As maintained above, some studies have evaluated the predictors of hope in chronic diseases.1719 However, only a single study was found on the psychological predictors of hope in hemodialysis patients.20 The spiritual and social predictors of hope have also been less addressed in hemodialysis patients. Therefore, the present study aims to determine the psychosocial, spiritual, and biomedical predictors of hope in hemodialysis patients.

Methods

This cross-sectional study was conducted in three hemodialysis centers in Namazee, Faghihi, and Sadra hospitals affiliated to Shiraz University of Medical Sciences in 2019. The participants included the hemodialysis patients diagnosed with ESRD at least one year ago. The inclusion criteria of the study were being Iranian and aging 18 years and above. The patients who suffered from psychiatric disorders and used psychiatric drugs were excluded from the study.

Based on a pilot study and considering α=0.05, probability of the type П error in hypothesis, β=0.85, and r=0.16 as the correlation coefficient between hope and depression, anxiety, and stress, a 311-subject sample size was estimated. Then, it was increased to 350 considering a 12% drop out. The participants were selected via convenience sampling.

The data were collected using the demographic and clinical characteristics form, biomedical markers form, and three questionnaires. The demographic and clinical characteristics form included some information about gender, marital status, education level, length of time on hemodialysis, number of dialysis sessions per week, and having diabetes, hypertension, and hyperlipidemia.

Interdialytic Weight Gain (IWG) and biomedical markers, such as, BUN, Creatinine (Cr), phosphate, sodium (Na), and K levels were assessed. IWG was measured by subtracting post-dialysis weight gain from pre-dialysis weight. In addition, the mean levels of the biomedical markers were calculated over two sequential months. BUN>100 mg/dL, K>6.5 mEq/L, phosphate>6.5 mg/dL, and IWG>2.5 Kg were considered as non-adherence to dietary and fluid restrictions.6

One of the data collection instruments was the Adult Hope Scale (https://ppc.sas.upenn.edu/sites/default/files/hopescale.pdf), which included Snyder’s cognitive model of hope.21 Adult Hope Scale consisted of 12 items. The patients responded to each item using an eight-point scale ranging from definitely false to definitely true.22 Adult Hope Scale contained two subscales, namely agency and pathway. Each subscale contained four items and the scores could range from a minimum of four to a maximum of 32. The total hope score was computed by summing the agency and pathway scores and could range from a minimum of eight to a maximum of 64. Higher scores indicated higher hope levels. The concurrent and divergent validity of this scale have been approved.23 The reliability of the Persian version of the scale was also confirmed via confirmatory factor analysis in the research by Yailagh et al.24 In the present study, the reliability of Adult Hope Scale was approved by Cronbach’s alpha=0.80.

Another instrument used in this study was the Depression Anxiety Stress Scales (DASS-21), (https://journals.plos.org/plosone/article/file?type=supplementaryandid=info:doi/10.1371/journal.pone.0219193.s004), which was designed by Lovibond and Lovibond in 1995. This scale consisted of 21 items responded based on a four-point Likert scale. The scores ranged from 0 to 63, with higher scores indicating higher levels of depression, anxiety, and stress. Each of the subscales of depression, anxiety, and stress consisted of seven items. The final score of each subscale was multiplied by two. Thus, the score of each subscale could range from 0 to 42. Accordingly, the scores of depression, anxiety, and stress scales were categorized into normal, mild, moderate, severe, and extremely severe categories (Table 1).25 The construct validity of DASS was approved by Szabo.26 Besides, Cronbach’s alpha coefficient of the Persian version of the scale was found to be 0.94. The Cronbach’s alpha coefficients of depression, anxiety, and stress subscales were also obtained as 0.86, 0.82, and 0.82, respectively.27 In the current study, the reliability of depression, anxiety, and stress subscales was approved by Cronbach’s alpha coefficients of 0.83, 0.79, and 0.80, respectively.

Table 1 DASS Severity Rating

The Personal Resources Questionnaire-85 (PRQ-85) Part II (https://www.ncbi.nlm.nih.gov/pubmed/3306610)28 was used to measure the patients’ perceived social support. PRQ-85 Part II contained 25 items responded via a seven-point Likert-type scale with end points of strongly disagree (1) and strongly agree (7). Thus, the total score of the questionnaire could range from 25 to 175, with higher scores representing higher levels of perceived social support.28 PRQ-85 has been used in some studies.5,29 Brandt and Weinert declared that the Cronbach’s alpha coefficient of the PRQ-85 Part II was 0.89.30 The validity of the Persian version of PRQ-85 Part II has been approved, as well. Its reliability has been also approved by the test re-test method (r=0.85) and Cronbach’s alpha=0.90.5 In the present study, the reliability of PRQ-85 Part II was approved by Cronbach’s alpha=0.85.

Spiritual Well-being Scale developed by Paloutzian and Ellison (1982)31 was also used in the current study. This scale contained 20 items responded via a six-point Likert scale. Hence, the total score of the scale could range from 20 to 120, with higher scores indicating greater spiritual well-being. The validity and reliability of the Persian version of the Spiritual Well-being Scale have been confirmed in the research by Abhari et al.32 In the current study, the reliability of the Spiritual Well-being Scale was approved by Cronbach’s alpha=0.79.

The data were collected by a researcher’s assistant who referred to the hemodialysis centers in the hospitals affiliated to Shiraz University of Medical Sciences and distributed the questionnaires among the participants.

This study was approved by the Ethics Committee of Shiraz University of Medical Sciences (IR.SUMS.REC.1397.209). All participants were requested to sign written informed consent forms, which included some information about the research objectives, participants’ activities, time for filling out the questionnaires, and voluntary nature of the research. Confidentiality of information and anonymity were also considered in this study.

The data were analyzed using the SPSS statistical software, version 22. In order to determine hope, depression, anxiety, and stress levels, perceived social support, and spiritual well-being, descriptive statistics such as frequency, percentage, mean, and standard deviation were used. The association between the study variables was assessed using Pearson’s correlation coefficient. Moreover, linear regression analysis was used to determine the factors associated with hope. The significance level was set at p<0.05.

Results

In this study, 390 hemodialysis patients were invited and 350 patients were enrolled. The response rate was 89.74%. The mean age of the participants was 53.46 years (SD=15.97). As shown in Table 2, approximately half of the participants were male (52%). Most of the participants were married (61.1%) and had primary and secondary school degrees (63.7%). In addition, 62.9% and 80.3% of the patients did not have the history of diabetes and hyperlipidemia, respectively. However, 70.6% reported the history of hypertension (Table 2).

Table 2 The Number and Percentage of the Demographic and Clinical Characteristics of the Hemodialysis Patients

The length of time on hemodialysis ranged from 12 to 228 months, with a mean of 50.86 (SD=30.01) months. Among the participants, 65 (18.6%) underwent hemodialysis twice a week and 285 (81.4%) did so three or more times per week.

The means and ranges of IWG, BUN, Cr, phosphate, Na, and K have been presented in Table 3. Accordingly, the majority of the participants adhered to IWG, phosphate, and K and all of them adhered to BUN (Table 3).

Table 3 Biomedical and Biological Values in the Hemodialysis Patients

The mean score of hope was 28.54 (SD=5.27), ranging from 15 to 38. The mean scores of agency and pathway subscales of hope were 14.12 (SD=2.94) and 14.41 (SD=2.72), respectively.

The mean scores of depression, anxiety, and stress were 17.87 (SD=7.62), 13.12 (SD=3.47), and 12.99 (SD=3.88), respectively. Accordingly, the patients suffered from moderate levels of depression and anxiety, but had normal levels of stress (Table 1).

The mean score of perceived social support was 126.35 (SD=17.53). Based on the results, the patients had high levels of perceived social support. In addition, the mean score of spiritual well-being was 74.02 (SD=5.84), which was approximately equal to two-thirds of the expected score; ie, 80.

The study results showed no significant associations between hope and age (r=−0.04, p=0.40), gender (r=−0.07, p=0.16), marital status (r=−0.06, p=0.20), education level (r=−0.02, p=0.61), having diabetes (r=0.08, p=0.13), having hypertension (r=0.04, p=0.43), and having hyperlipidemia (r=−0.07, p=0.18). The results also revealed no significant associations between hope and IWG (r=0.09, p=0.06), BUN (r=0.05, p=0.29), Cr (r=0.004, p=0.93), phosphate (r=−0.08, p=0.11), Na (r=−0.03, p=0.50), and K (r=0.02, p=0.62). However, a significant association was observed between hope and depression (r=−0.19, p<0.001), anxiety (r=−0.37, p<0.001), stress (r=−0.33, p<0.001), perceived social support (r=0.49, p<0.001), and spiritual well-being (r=0.11, p=0.03). The variables associated with hope, including depression, anxiety, stress, perceived social support, and spiritual well-being, were entered into the linear regression analysis. Backward linear regression analysis was used to determine the predictors of hope. The results showed that 35% of the changes in hope were explained by the abovementioned factors. The correlation coefficient between hope and the abovementioned variables was 0.59. Among these variables, the associations between hope and anxiety, stress, and perceived social support were statistically significant (p<0.05). However, other variables including depression and spiritual well-being were not significantly associated with hope (p>0.05) (Table 4).

Table 4 The Association Between Hope and Depression, Anxiety, Stress, Perceived Social Support, and Spiritual Well-Being in the Hemodialysis Patients

Discussion

This study aimed to determine the psychosocial, spiritual, and biomedical predictors of hope in hemodialysis patients. Assessing all aspects of human life as the predictors of hope in hemodialysis patients made this study different from the previous studies.

The mean score of hope was 28.54 (SD=5.27), which ranged from 27 to 45. This was close to two-thirds of the expected score of hope or the moderate level. Tavassoli et al indicated that the mean score of hope was 36.36 in hemodialysis patients.33 Similarly, Gao et al reported a moderate mean score of hope among hemodialysis patients.34 However, a study on hope in hemodialysis patients demonstrated that most of the participants (62%) had high levels of hope.35 The moderate level of hope in the present study might be due to fear from the future, unpleasant complications, or even death. Therefore, hemodialysis patients could not be expected to have high levels of hope. The only way to save hemodialysis patients is kidney transplantation, which is accompanied with some side effects and complications. Therefore, finding a kidney donor could create hope for these patients.

The study results revealed that the hemodialysis patients suffered from moderate levels of depression and anxiety. However, they had normal stress levels. Based on a study, 64% of hemodialysis patients had low anxiety levels, while 36% suffered from moderate and high levels of anxiety. Moreover, 70.5% of the participants reported low levels of depression, while 17.1% and 12.3% showed moderate and high levels of depression, respectively.7 In fact, renal failure impacts the hemodialysis patients’ emotional status as a result of dietary and fluid restrictions, pain, and fatigue.36 Therefore, it leads to psychological issues, such as depression and anxiety.

The present study results showed that the mean score of perceived social support was 126.35. Consistently, another study indicated that the mean score of perceived social support was 131.93 among Iranian hemodialysis patients.5

In the current study, the mean score of spiritual well-being was 74.02, which was approximately equal to two-thirds of the expected score; ie, 80. Similarly, a prior study revealed that the mean score of spiritual well-being was 75.05 and at the moderate level among hemodialysis patients.35 It was also found previously that Iranian hemodialysis patients had high levels of spiritual health.33 Iranian Muslim people had strong spiritual beliefs and used spirituality to cope with chronic diseases.14

The findings of the present study revealed a relationship between hope and psychological issues, including depression, anxiety, stress, perceived social support, and spiritual well-being. Moreover, the results of regression analysis showed that the associations between hope and anxiety, stress, and perceived social support were statistically significant. Hope therapy reduced depression, anxiety, and stress in hemodialysis patients.37 Hope was also associated with spiritual well-being,35 spiritual health,16,33 and perceived social support38 in dialysis patients. In fact, hope predicted the quality of life in these patients.17 Furthermore, hope was associated with functional, social, and emotional well-being,18 depression symptoms,39 depression, and self-esteem19 in chronic conditions.

The current study findings demonstrated that 35% of the changes in hope were explained by depression, anxiety, stress, perceived social support, and spiritual well-being. Therefore, future studies are suggested to assess other factors associated with hope among hemodialysis patients.

Considering the association between hope and psychological issues, patients’ anxiety, depression, and stress can be decreased by increasing hope in hemodialysis wards and clinical settings. Therefore, conducting interventions to enhance hope might be effective in this regard.

This study had some limitations, one of which being its cross-sectional design. Hence, further longitudinal studies in this field are warranted. Another study limitation was not controlling the confounding factors. Therefore, the confounding factors of hope are recommended to be assessed and controlled in future investigations.

Conclusion

The present study results showed that the mean score of hope was close to two-thirds of the expected score or at the moderate level. Moreover, the hemodialysis patients suffered from moderate levels of depression and anxiety. However, they had normal stress levels. They also had high levels of perceived social support. The results revealed an association between hope and depression, anxiety, stress, perceived social support, and spiritual well-being. Other factors associated with hope in hemodialysis patients are recommended to be assessed in future investigations.

Ethical Consideration

This study was approved by the Ethics Committee of Shiraz University of Medical Sciences (IR.SUMS.REC.1397.209). It was also confirmed that the study was conducted in accordance with the Declaration of Helsinki.

Acknowledgments

This article was the result of the Master’s thesis written by Mahsa Mokhtarizadeh. It was approved by Shiraz University of Medical Sciences (No. 16683). The authors would like to thank Shiraz University of Medical Sciences and health care providers of the hemodialysis wards affiliated to Shiraz University of Medical Sciences for their cooperation. They would also like to appreciate all 350 hemodialysis patients who participated in the study. Thanks also go to the Center for Development of Clinical Research of Nemazee Hospital for statistical consultation. Last but not least, Ms. A. Keivanshekouh at the Research Improvement Center of Shiraz University of Medical Sciences is acknowledged for improving the use of English in the manuscript.

Funding

This study was financially supported by Shiraz University of Medical Sciences.

Disclosure

The authors report no conflicts of interest in this work.

References

1. Brunner LS. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. 13th ed. Lippincott Williams & Wilkins; 2018.

2. Velásquez IM, Causadias MT, Valdés R, et al. End-stage renal disease—financial costs and years of life lost in Panama: a cost-analysis study. BMJ Open. 2019;9(5):e027229. doi:10.1136/bmjopen-2018-027229

3. Lv J-C, Zhang L-X. Prevalence and Disease Burden of Chronic Kidney Disease. Renal Fibrosis: Mechanisms and Therapies. Springer; 2019:3–15.

4. Rambod M, Shabani M, Shokrpour N, Rafii F, Mohammadalliha J. Quality of life of hemodialysis and renal transplantation patients. Health Care Manag (Frederick). 2011;30(1):23–28. doi:10.1097/HCM.0b013e3182078ab6

5. Rambod M, Rafii F. Perceived social support and quality of life in Iranian hemodialysis patients. J Nurs Scholarship. 2010;42(3):242–249. doi:10.1111/j.1547-5069.2010.01353.x

6. Rambod M, Peyravi H, Shokrpour N, Sareban MT. Dietary and fluid adherence in iranian hemodialysis patients. Health Care Manag (Frederick). 2010;29(4):359–364. doi:10.1097/HCM.0b013e3181fa0691

7. Gerogianni G, Polikandrioti M, Babatsikou F, et al. Anxiety–depression of dialysis patients and their caregivers. Medicina. 2019;55(5):168. doi:10.3390/medicina55050168

8. Liu Y-M, Chang H-J, Wang R-H, Yang L-K, Lu K-C, Hou Y-C. Role of resilience and social support in alleviating depression in patients receiving maintenance hemodialysis. Ther Clin Risk Manag. 2018;14:441. doi:10.2147/TCRM.S152273

9. Al-Arabi S. Quality of life: subjective descriptions of challenges to patients with end stage renal disease. Nephrol Nurs J. 2006;33(3):285–292.

10. Sousa H, Ribeiro O, Paúl C, et al., editors. Social support and treatment adherence in patients with end‐stage renal disease: a systematic review. Seminars in Dialysis; 2019: Wiley Online Library.

11. Tezel A, Karabulutlu E, Şahin Ö. Depression and perceived social support from family in Turkish patients with chronic renal failure treated by hemodialysis. J Res Med Sci. 2011;16(5):666.

12. Irajpour A, Hashemi MS, Abazari P, Shahidi S, Fayazi M. The effects of peer support on depression, anxiety, and stress among patients receiving hemodialysis. Iran Red Crescent Med J. 2018;20(S1):e66321.

13. Moons P, Luyckx K, Dezutter J, et al. Religion and spirituality as predictors of patient-reported outcomes in adults with congenital heart disease around the globe. Int J Cardiol. 2019;274:93–99. doi:10.1016/j.ijcard.2018.07.103

14. Rambod M, Sharif F, Molazem Z, Khair K. Spirituality experiences in hemophilia patients: a phenomenological study. J Relig Health. 2019;58(3):992–1002. doi:10.1007/s10943-018-0621-3

15. Jaberi A, Momennasab M, Yektatalab S, Ebadi A, Cheraghi MA. Spiritual health: A concept analysis. J Relig Health. 2019;58(5):1537–1560. doi:10.1007/s10943-017-0379-z

16. Ottaviani AC, Souza ÉN, Drago NDC, Mendiondo MSZD, Pavarini SCI, Orlandi FDS. Hope and spirituality among patients with chronic kidney disease undergoing hemodialysis: a correlational study. Rev Lat Am Enfermagem. 2014;22(2):248–254. doi:10.1590/0104-1169.3323.2409

17. Al-Rawashdeh S, Alshraifeen A, Rababa M, Ashour A. Hope predicted quality of life in dyads of community-dwelling patients receiving hemodialysis and their family caregivers. Quality Life Res. 2020;29(1):81–89. doi:10.1007/s11136-019-02378-4

18. Grealish L, Hyde MK, Legg M, et al. Psychosocial predictors of hope two years after diagnosis of colorectal cancer: implications for nurse‐led hope programmes. Eur J Cancer Care (Engl). 2019;28(3):e13010. doi:10.1111/ecc.13010

19. Balsanelli ACS, Grossi SAA. Predictors of hope among women with breast cancer during chemotherapy. Rev Da Escola De Enfermagem Da USP. 2016;50(6):898–904. doi:10.1590/s0080-623420160000700004

20. Billington E, Simpson J, Unwin J, Bray D, Giles D. Does hope predict adjustment to end‐stage renal failure and consequent dialysis? Br J Health Psychol. 2008;13(4):683–699. doi:10.1348/135910707X248959

21. Snyder CR, Harris C, Anderson JR, et al. The will and the ways: development and validation of an individual-differences measure of hope. J Pers Soc Psychol. 1991;60(4):570. doi:10.1037/0022-3514.60.4.570

22. Snyder CR. Hope theory: rainbows in the mind. Psychol Inq. 2002;13(4):249–275. doi:10.1207/S15327965PLI1304_01

23. DiGasbarro D, Midden A, Van Haitsma K, Meeks S, Mast B. Reliability and validity of the adult hope scale among nursing home residents with and without cognitive impairment. Clin Gerontol. 2020;43(3):340–349. doi:10.1080/07317115.2019.1656696

24. Yailagh MS, Ghahfarokhi FK, Maktabi GH, Neasi A, Samavi A. Reliability and validity of the Hope Scale in the Iranian students. J Life Sci Biomed. 2012;2(4):125–128.

25. Lovibund S, Lovibund P. Manual for the Depression Anxiety Stress Scales. Sydney: Psychology Foundation; 1995.

26. Szabó M. The short version of the depression anxiety stress scales (DASS-21): factor structure in a young adolescent sample. J Adolesc. 2010;33(1):1–8. doi:10.1016/j.adolescence.2009.05.014

27. Edraki M, Rambod M. Psychological predictors of resilience in parents of insulin-dependent children and adolescents. Int J Community Based Nurs Midwifery. 2018;6(3):239.

28. Weinert C, Brandt PA. Measuring social support with the personal resource questionnaire. West J Nurs Res. 1987;9(4):589–602. doi:10.1177/019394598700900411

29. Tawalbeh LI, Ahmad MM. Personal resource questionnaire: A systematic review. J Nurs Res. 2013;21(3):170–177. doi:10.1097/01.jnr.0000432049.31921.ab

30. Brandt PA, Weinert C. The PRQ: A social support measure. Nurs Res. 1981;30(5):277???280. doi:10.1097/00006199-198109000-00007

31. Paloutzian R, Ellison C. Loneliness, Spiritual Well-Being and Quality. Peplau L and Perlman D Loneliness: A Sourcebook of Current Theory Wiley Interscience. New York; 1982.

32. Abhari MB, Fisher JW, Kheiltash A, Nojomi M. Validation of the persian version of spiritual well-being questionnaires. Iran J Med Sci. 2018;43(3):276.

33. Tavassoli N, Darvishpour A, Mansour-Ghanaei R, Atrkarroushan Z. A correlational study of hope and its relationship with spiritual health on hemodialysis patients. J Educ Health Promot. 2019;8(1):146. doi:10.4103/jehp.jehp_461_18

34. Gao Y, Zhou Y, Guo C-X, Zhao J-F. The relationship among hope, symptom distress, social support, coping style and monthly income in maintenance hemodialysis patients: a structural equation model. Int J Clin Exp Med. 2016;9(10):19717–19724.

35. Ghahfarokhi MM, Mohammadian S, Nezhad BM, Kiarsi M. Relationship between spiritual health and hope by dietary adherence in haemodialysis patients in 2018. Nurs Open. 2020;7(2):503. doi:10.1002/nop2.412

36. Davison SN, Jhangri GS. Impact of pain and symptom burden on the health-related quality of life of hemodialysis patients. J Pain Symptom Manage. 2010;39(3):477–485. doi:10.1016/j.jpainsymman.2009.08.008

37. Rahimipour M, Shahgholian N, Yazdani M. Effect of hope therapy on depression, anxiety, and stress among the patients undergoing hemodialysis. Iran J Nurs Midwifery Res. 2015;20(6):694. doi:10.4103/1735-9066.170007

38. Goktas S, Camdeviren EK, Gezginci E, Kosucu SN, editors. Social Support Perceptions and Hope Levels of Patients Waiting for Organ Transplantation. In: Transplantation Proceedings. Elsevier; 2019.

39. Fischer IC, Cripe LD, Rand KL. Predicting symptoms of anxiety and depression in patients living with advanced cancer: the differential roles of hope and optimism. Supportive Care Cancer. 2018;26(10):3471–3477. doi:10.1007/s00520-018-4215-0

Creative Commons License © 2020 The Author(s). This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution - Non Commercial (unported, v3.0) License. By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms.