Effect of Participation in Peer-Support Groups on Happiness and Life Orientation in Mothers of Children Undergoing Hemodialysis

Introduction

The prevalence of alternative renal replacement therapies in children and adolescents aged under 20 years is about 65 per one million population worldwide (1). Therefore, hemodialysis (HD) has been recognized as an alternative therapy and a common method to control chronic kidney disease (CKD) (2). During HD, mothers often assume the role of primary caregivers of their children and devote themselves entirely to this job (3). Mothers need to provide health care services to their children in addition to their parenting role, which imposes much stress and emotional pressure on them (4-5). Such mothers also feel that they are neglected and lonely in caring for their children, and even find that those around them, including family and medical staff, do not understand their conditions (6). According to Geense et al. (2017), mothers who provide care and treatment to their children notice that these responsibilities interfere with their other responsibilities at work and in social and family life (7). Consequently, these mothers are subjected to high levels of psychological tension (6) that often leads to the appearance of severe depression and anxiety symptoms (8). A collection of problems such as aggression, depression, and anxiety can give rise to psychosis and decline in mental health status and feeling of happiness in mothers of children with special needs (9).

The feeling of happiness is a measure of one’s mental health and has numerous tangible benefits, such as improvement of physical health, reduction of psychological distress, and increase in life expectancy (10). Moreover, the feeling of happiness is an important variable that affects human life and somehow bestows meaning to life (11), as the most urgent natural and psychological needs in humans (12). Happiness can indirectly lead to improved medical and psychosocial outcomes and enhance the performance of patients and their families (13-14).

Quality of life is among the psychosocial factors that contribute to the successful implementation of medical treatments (15). Parents of children undergoing HD experience low levels of quality of life (16). Life orientation is one of the components of quality of life (17), which affects chronic diseases and conditions (18). Life orientation refers to the way people look at their lives and is comprised of two dimensions of optimism and pessimism (15). The sense of optimism plays a role in individuals ’mental health status (19); therefore, optimists experience more psychological well-being and less stress in dealing with anxiety, act more dynamically and report higher satisfaction in life (20).

Mothers need emotional support to cope with their children’s chronic diseases. They even need support from their spouse, family, and friends even if it is others’ understanding and empathy or sharing of emotions (14). In the same line, peer support plays an important role in the maintenance of health in individuals and reduction of negative outcomes of stress; therefore, it has a direct effect on the quality of life. Peer support means using the support of an individual who adopts the most effective management style to improve his/her health based on empirical knowledge (21). Participants in peer-support group (PSG) sessions help individuals to socialize and connect with others (22). The PSG intervention is more effective than usual care in reducing the symptoms of depression, psychosocial distress, anxiety, and anger in patients (23, 24). The results of a study conducted by Ashktorab et al. (2013) demonstrated the impact of sharing positive experiences with peer patients on the way one manages chronic diseases (22). The results of another qualitative study further revealed that mothers of children undergoing HD preferred to meet peers with the same conditions to share their experiences. At present, all professional care teams have their focus on HD in children; therefore, their mothers as the primary caregivers have been ignored so far (6). To the best of the authors’ knowledge and based on the review of literature, no research was conducted in this domain. Therefore, the present study aimed to determine the effect of participation in PSG sessions on happiness and life orientation in mothers of children undergoing HD.

Methods

This longitudinal single-group study with interventional study design no control group was conducted at Dr. Sheikh Hospital, Mashhad, Iran, during 2019-2020. The study samples (n=30) were selected using the convenience sampling technique from the mothers who had met the inclusion criteria and were referred to this hospital (for the HD of their children) at the time of the study. The sample size adequacy was measured considering the confidence level of 95%, and based on the comparison of two means formula. The margin of error was 5%, and the variance of means was estimated at 45.

Accordingly, the minimum and sufficient required sample size were estimated at 18 in this study. The inclusion criteria included at least two months of HD at minimum, lack of uncontrolled mental disorders in mothers, lack of visual and hearing impairments, lack of debilitating acute and chronic disease risk, and lack of extreme stress except for their children’s illnesses in the last six months. However, those mothers who refused to continue participation in the study, were absent in more than two PSG sessions, developed acute diseases or were hospitalized during the study, and discontinued HD due to kidney transplant or death of children were excluded from the study.

The data collection tools included the demographic characteristics/ medical history questionnaire, the Oxford Happiness Inventory (OHI), and the Revised Life Orientation Test (LOT-R).

The OHI, developed by Argyle, Martin, and Crossland (1989), included 29 items in a 4-point Likert scale. Each point in this scale was scored from 0 to 3 and the total score ranged from 0 to 87 (25-26). The LOT-R, designed by Scheier and Carver (1992), was consisted of 10 items, including three items with positive statements and three items with negative statements. Each item was scored based on a five-point Likert-type scale (from strongly disagree to strongly agree). Items 1, 4, and 10 were scored directly, and items 3, 7, and 9 were scored in reverse. Moreover, items 2, 5, 6, and 7 were complementary (i.e. items used to ensure that a respondent was not sensitive to the main items of the test). The total scores ranged from 0 to 24, wherein a higher score indicated a greater tendency to expect positive results versus negative ones (27).

The content validity of the demographic characteristics/medical history questionnaire was confirmed by seven faculty members of the School of Nursing and Midwifery affiliated to Mashhad University of Medical Sciences, Mashhad, Iran, and their corrections and opinions were applied. The reliability of the OHI had also been reported to be optimal in the studies by Liaghatdar et al. (2008) and Alipour et al. (2007; 26, 28), and all its 29 items were highly correlated with the total score. The Cronbach’s alpha coefficient for the entire questionnaire was 91. The convergent and divergent validity of the scale has been further established. As well, the study results had shown the validity of this test for measuring happiness in Iranian society (26). In the present study, the reliability of the scale was confirmed through the determination of the internal consistency by the calculation of the Cronbach’s alpha coefficient for 10 people which was estimated at 0.89. The reliability of the LOT-R had been already been estimated at 0.70, using the Cronbach’s alpha coefficient (18). In the present study, the reliability of the LOT-R was confirmed by the internal consistency method through the calculation of the Cronbach’s alpha coefficient for 10 people determined at 0.83. 

In total, 32 children were undergoing HD at Dr. Sheikh Hospital, Mashhad, Iran. The mother of one child did not attend any of the HD sessions and another child did not meet the inclusion criteria less than two months after the first HD. As a result, 30 mothers entered the study. Initially, the purpose of the study was explained to the participants and informed consent was obtained. Subsequently, the mothers were divided into six groups of 4-5 people based on their children’s HD program. Afterward, five PSG sessions were held for each group (each session lasting from 1 to 1.5 h) two times a week starting from 7 July 2020. During the intervention, three mothers were excluded from the study due to their absence in more than three PSG sessions (following the kidney transplant of their children and traveling to their hometown). Eventually, the intervention was conducted on 27 mothers.

The topics of the PSG sessions were extracted from the needs assessment in a similar study conducted by Pourghaznein et al. in 2018 (6) and included informational, mental-psychological, financial, functional, and physical needs. Some questions related to the need for support were raised by the researcher within the first five minutes of each session. Mothers had 10 minutes to write down whatever was on their minds and then communicate their experiences and propose their solutions in relation to the questions raised. In each session, mothers were asked to employ approaches to adapt to changes and use other people’s experiences and views to deal with their relevant problems and cope with the present situation and the new concept of life. The PSG sessions were mother-centered, wherein the mothers could provide and maintain the dynamicity of the group and then share experiences and opinions regarding the questions posed.

In the PSG sessions, the researcher was only a facilitator who tried to boost the effectiveness of the group, accelerate group discussions, provide scientifically correct information, reflect on the group dynamics process, provide feedback to members, and avoid the exchange of wrong