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Roberts E, Zelikovsky N. Family Environment, Social Support, and Health-Related Quality of Life in Adolescents Following Kidney Transplant. Pediatr Transplant 2024; 28:e14824. [PMID: 38992881 DOI: 10.1111/petr.14824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 06/17/2024] [Accepted: 06/27/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND Kidney transplantation is the treatment of choice for pediatric end-stage renal disease. Transplant recipients often have better neurocognitive, academic, and health-related outcomes. While there is some evidence that health-related quality of life (HRQOL) improves following kidney transplant, other studies have found adolescent transplant recipients report lower overall HRQOL than healthy peers. Current research has focused on individual-level factors affecting adjustment to organ transplant, warranting examination of HRQOL from a systems perspective. Family environment and social support contribute to a system of proximal relationships that are crucial in adolescents' development, making them important factors to study in relation to HRQOL post-transplant. METHODS The current study utilized archival data of adolescent renal transplant patients who completed surveys about their family environment, social support, and HRQOL during routine transplant clinic visits. RESULTS Family cohesion, as well as social support from parents, classmates, and people in school, were positively correlated with HRQOL. Social support from people in school uniquely predicted variance in HRQOL, beyond the contribution of overall family environment after controlling for demographic factors. Relative to comparable adolescent samples, transplant recipients reported more optimal overall family environment, greater social support from teachers, and lower social support from close friends. CONCLUSION Psychosocial interventions for adolescent kidney transplant recipients may be enhanced by collaborating with school professionals and further bolstering strengths in the family environment. Kidney transplant recipients may benefit from long-term intervention, as decreased HRQOL appears to persist years post-transplant.
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Affiliation(s)
- Emma Roberts
- Department of Psychology, La Salle University, Philadelphia, Pennsylvania, USA
| | - Nataliya Zelikovsky
- Department of Psychology, La Salle University, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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2
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Hu N, Wang A, Chang T. Social support mediates the relationship between illness perception and psychosocial adaptation among young and middle-aged kidney transplant recipients in China. Front Psychol 2023; 14:1062337. [PMID: 36910788 PMCID: PMC9998938 DOI: 10.3389/fpsyg.2023.1062337] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 02/08/2023] [Indexed: 03/14/2023] Open
Abstract
Background No research has yet been done on social support's influence on the association between illness perception and psychosocial adaptation among young and middle-aged kidney transplant recipients in China. Accordingly, it remains unclear how medical personnel can assist patients in successfully adjusting to the early postoperative period and improving their health. Objective This study sought to explore the influence of illness perception and social support on the psychosocial adaptation of young and middle-aged recipients of kidney transplants in China during the early postoperative period. Methods This study adopted a cross-sectional design. The study included 236 young and middle-aged kidney transplant recipients from a tertiary hospital in China. Demographic and disease-related data were collected. Additionally, the Psychosocial Adjustment to Illness Scale-Self-Report, the Brief Illness Perception Questionnaire, and the Multidimensional Scale of Perceived Social Support were used to assess participants' psychosocial adaptation, illness perception, and social support, respectively. The model was examined using descriptive analysis, Pearson's correlation analysis, hierarchical multiple regression analysis, and the PROCESS Macro in SPSS 26.0. Results A total of 176 (74.56%) participants reported an average psychosocial adaptation score >50, which is relatively negative. Marital status, education level, residence, per capita monthly income (in Chinese yuan), medical insurance, work status, post-transplant time, body mass index, creatinine status, and complications were all related to psychosocial adaptation (p < 0.05). The more negative their illness perception and the worse their social support, the worse the psychosocial adaptation of young and middle-aged kidney transplant recipients. Further, the effect of illness perception on psychosocial adaptation was partially mediated by social support (36.56%). Conclusion In general, the psychosocial adaption level of young and middle-aged kidney transplant recipients was negative during the early postoperative period. Healthcare teams should assist patients in building a positive illness perception shortly following kidney transplantation, while also providing psychological care and support to help them cope with the onset of psychosocial issues.
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Affiliation(s)
- Na Hu
- Transplantation Department, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Aiping Wang
- Department of Public Service, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Tiantian Chang
- Transplantation Department, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
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3
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Meta-Analysis for Social Support Degree of Kidney Transplant Recipients: Evidence from China. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:9998947. [PMID: 34422252 PMCID: PMC8378972 DOI: 10.1155/2021/9998947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 06/13/2021] [Accepted: 07/29/2021] [Indexed: 11/23/2022]
Abstract
Social support refers to the subjective and (or) objective influence of various social relationships on individuals, which has a certain influence on the negative emotions of the kidney transplant patients. But there are still significant differences among various studies, so we performed a meta-analysis to analyze the social support degree of kidney transplant recipients. This article searched and selected the relevant cross-sectional surveys from PubMed, Embase, VIP, CNKI, Wanfang, and CBM databases according to the inclusion and exclusion criteria and used the STROBE list combined with the observational research quality evaluation tools of Sanderson to conduct the quality appraisal. The “meta” and “metaphor” packages of the R software version 3.5.1 were used for the meta-analysis. A total of 17 studies with 2697 patients were included. The total scores of the social support and objective support of the renal transplant patients were abundant after the operation, indicating that the economic, physical, and emotional supports from the family, society, and the official organization are accepted. But the subjective support and support utilization degree were general. The support utilization was different among different genders, and female patients were lower than the males. In particular, the female patients relatively presented autism and the social support utilization degree was low. Medical staffs are needed to join the family, hospital, and society to create favorable conditions and improve the social support system and the utilization degree of the social support, thereby promoting the physical and mental health development of the patients.
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Battaglia Y, Zerbinati L, Piazza G, Martino E, Massarenti S, Provenzano M, Esposito P, Andreucci M, Storari A, Grassi L. The Use of Demoralization Scale in Italian Kidney Transplant Recipients. J Clin Med 2020; 9:E2119. [PMID: 32635625 PMCID: PMC7408932 DOI: 10.3390/jcm9072119] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 07/02/2020] [Accepted: 07/03/2020] [Indexed: 02/07/2023] Open
Abstract
Demoralization is a commonly observed syndrome in medically ill patients. The risk of demoralization may increase in patients after a kidney transplant (KTRs) because of the stressful nature of renal transplantation, psychosocial challenges, and adjustment needs. No study is available on demoralization amongst KTRs. The purpose of our study was to evaluate the validity of the Italian version of the Demoralization Scale (DS-IT) and the prevalence of demoralization in KTRs. Also, we aimed at exploring the association of the DS-IT with International Classification of Diseases (ICD) psychiatric diagnoses, post-traumatic growth (PTG), psychological and physical symptoms, and daily-life problems. A total of 134 KTRs were administered the MINI International Neuropsychiatric Interview 6.0. and the Diagnostic Criteria for Psychosomatic Research-Demoralization (DCPR/D) Interview. The DS-IT, the Edmonton Symptom Assessment System (ESAS), the Canadian Problem Checklist (CPC), were used to measure demoralization, physical and psychological symptoms, and daily-life problems; also, positive psychological experience of kidney transplantation was assessed with the PTG Inventory. Routine biochemistry and sociodemographic data were collected. Exploratory factor analysis demonstrated a four-dimensional factor structure of the DS-IT, explaining 55% of the variance (loss of meaning and purpose, disheartenment, dysphoria, and sense of failure). DS-IT Cronbach alpha coefficients indicated good or acceptable level of internal consistency. The area under the Receiving Operating Characteristics (ROC) curve for DS-IT (against the DCPR/D interview as a gold standard) was 0.92. The DS-IT optimal cut-off points were ≥20 (sensitivity 0.87, specificity 0.82). By examining the level of demoralization, 14.2%, 46.3%, 24.6%, and 14.6% of our sample were classified as having no, low, moderate, and high demoralization, respectively, with differences according to the ICD psychiatric diagnoses (p < 0.001). DS-IT Total and subscales scores were positively correlated with scores of ESAS symptoms and CPC score. A correlation between DS-IT loss of meaning and purpose subscale and PTGI appreciation of life subscale (p < 0.05) was found. This study shows, for the first time, a satisfactory level of reliability of the DS-IT and a high prevalence of severe demoralization in KTRs.
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Affiliation(s)
- Yuri Battaglia
- Nephrology and Dialysis Unit, St. Anna University Hospital, 44124 Ferrara, Italy;
| | - Luigi Zerbinati
- Department of Biomedical and Specialty Surgical Sciences, Institute of Psychiatry, University of Ferrara, 44124 Ferrara, Italy; (L.Z.); (G.P.); (E.M.); (S.M.); (L.G.)
| | - Giulia Piazza
- Department of Biomedical and Specialty Surgical Sciences, Institute of Psychiatry, University of Ferrara, 44124 Ferrara, Italy; (L.Z.); (G.P.); (E.M.); (S.M.); (L.G.)
| | - Elena Martino
- Department of Biomedical and Specialty Surgical Sciences, Institute of Psychiatry, University of Ferrara, 44124 Ferrara, Italy; (L.Z.); (G.P.); (E.M.); (S.M.); (L.G.)
| | - Sara Massarenti
- Department of Biomedical and Specialty Surgical Sciences, Institute of Psychiatry, University of Ferrara, 44124 Ferrara, Italy; (L.Z.); (G.P.); (E.M.); (S.M.); (L.G.)
| | - Michele Provenzano
- Nephrology and Dialysis Unit, Department of Health Sciences, Magna Graecia University, 88100 Catanzaro, Italy; (M.P.); (M.A.)
| | - Pasquale Esposito
- Division of Nephrology, Dialysis and Transplantation, Department of Internal Medicine, University of Genoa and IRCCS Ospedale Policlinico San Martino, 16132 Genoa, Italy;
| | - Michele Andreucci
- Nephrology and Dialysis Unit, Department of Health Sciences, Magna Graecia University, 88100 Catanzaro, Italy; (M.P.); (M.A.)
| | - Alda Storari
- Nephrology and Dialysis Unit, St. Anna University Hospital, 44124 Ferrara, Italy;
| | - Luigi Grassi
- Department of Biomedical and Specialty Surgical Sciences, Institute of Psychiatry, University of Ferrara, 44124 Ferrara, Italy; (L.Z.); (G.P.); (E.M.); (S.M.); (L.G.)
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Cipolletta S, Entilli L, Nucci M, Feltrin A, Germani G, Cillo U, Volpe B. Psychosocial Support in Liver Transplantation: A Dyadic Study With Patients and Their Family Caregivers. Front Psychol 2019; 10:2304. [PMID: 31649602 PMCID: PMC6795706 DOI: 10.3389/fpsyg.2019.02304] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 09/27/2019] [Indexed: 12/17/2022] Open
Abstract
Background and aims: Liver transplantation provides an opportunity of survival for patients with liver failure; however, this procedure is known to be psychologically and physically fatiguing for patients and their informal caregivers. The aim of this study was to investigate how perceived social support and the distribution of dependency were associated with the psychological wellbeing of patients waiting for liver transplantation and their caregivers, as a dyad. Methods: The present was a cross-sectional study. Ninety-five participants were recruited at a hospital in Northern Italy, during the psychological evaluation for inclusion in the transplantation list: 51 patients (19 with alcohol-related illness) and 44 family caregivers. Both patients and caregivers filled in a Symptom Checklist and Kelly’s Dependency Grids. Patients also compiled the Medical Outcome Study Social-Support Survey, and caregivers compiled the Family Strain Questionnaire Short-Form. Results: Caregivers reported important levels of strain and strongly related to a worsening of their own and patients’ symptoms. Patients with alcohol-related pathologies had a narrower social network, which corresponded to an increase in family strain. On the sample as a whole, regression analyses showed that perceived social support and dependency measures did not predict patients’ and caregivers’ symptoms. Nevertheless, cluster analysis identified a group of caregivers who distributed their dependency more and experienced lower levels of depression, anxiety, and strain. Conclusions: These results suggest the usefulness of a dyadic approach in the research, prevention, and care of liver diseases. A deeper comprehension of the functioning of dyads will help practitioners in the identification of situations at risk.
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Affiliation(s)
| | - Lorenza Entilli
- Department of General Psychology, University of Padua, Padua, Italy
| | - Massimo Nucci
- Department of General Psychology, University of Padua, Padua, Italy
| | | | - Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplantation Unit, Department of General Surgery and Organ Transplantation, Padua University Hospital, Padua, Italy
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Swanson A, Geller J, DeMartini K, Fernandez A, Fehon D. Active Coping and Perceived Social Support Mediate the Relationship Between Physical Health and Resilience in Liver Transplant Candidates. J Clin Psychol Med Settings 2019; 25:485-496. [PMID: 29546621 DOI: 10.1007/s10880-018-9559-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Without a transplant, end-stage liver disease is associated with significant morbidity and mortality. Transplant candidates endure physical and psychological stress while awaiting surgery, yet little is known about the relationship between physical health and psychological resilience during the wait-list period. This study examined predictors of psychological resilience and mediators of the relationship between physical health and psychological resilience in liver transplant candidates. Wait-listed candidates (N = 120) from a single Northeast transplant center completed assessments of physical functioning, coping, perceived social support, and resilience. Findings revealed that physical functioning, active coping, and perceived social support were positively associated with resilience; maladaptive coping was negatively associated with resilience. Perceived social support and active coping partially mediated the relationship between physical functioning and resilience. Transplant center care providers should promote active coping skills and reinforce the importance of effective social support networks. These interventions could increase psychological resilience among liver transplant candidates.
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Affiliation(s)
- Amelia Swanson
- Department of Psychiatry, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA.
| | - Jessica Geller
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA.,Department of Veterans Affairs, Denver-Seattle Center of Innovation, Aurora, CO, USA
| | - Kelly DeMartini
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA.,Smilow Cancer Hospital at Yale-New Haven, New Haven, CT, USA.,Yale-New Haven Transplantation Center, New Haven, CT, USA
| | - Anne Fernandez
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Dwain Fehon
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA.,Smilow Cancer Hospital at Yale-New Haven, New Haven, CT, USA.,Yale-New Haven Transplantation Center, New Haven, CT, USA
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7
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Chen G, Bell CS, Loughhead P, Ibeche B, Bynon JS, Hall DR, De Golovine A, Edwards A, Dar WA. Exploration of the Stanford Integrated Psychosocial Assessment for Transplantation With Psychosocial and Medical Outcomes in Kidney and Kidney–Pancreas Transplant Recipients. Prog Transplant 2019; 29:230-238. [DOI: 10.1177/1526924819854480] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) is a psychometric instrument designed to assess patient risk for transplant. We investigated the association between SIPAT scores and demographic data with psychosocial and medical outcomes within a diverse kidney/kidney–pancreas transplant population. Design: The SIPAT was administered to all pretransplant candidates. A retrospective review of transplanted patients who had at least 6 months of follow-up was completed. Results: The sample included 136 patients: male (n = 77 [57%]) with a mean age of 47 years old. Thirty-eight percent were black (n = 51), 55% had less than a high school education (n = 74), and 65% had low socioeconomic status (n = 89). Statistical difference was found among SIPAT scores and substance use and support system instability ( P = .035, P = .012). Females ( P = .012) and patients with a history of psychopathology ( P = .002) developed or had a relapse of psychopathology following transplant. Patients with more than a high school education ( P = .025) and who were less than 30 years ( P = .026) had higher rejection incidence rates. Risk factors for rehospitalizations included Hispanic race, diabetes, and low socioeconomic status ( P = .036, P = .038, P = .014). African American/Black and male patients had higher incidence of infection events ( P = .032, P = .049). Mortality and treatment nonadherence were not significantly associated with SIPAT scores or demographic variables. Conclusion: The SIPAT was associated with posttransplant substance use and support system instability, while demographic variables were associated with the development and/or relapse of psychopathology, graft loss, rejection, infection events, and medical rehospitalizations. Revision of the SIPAT to include additional demographic components may lend to improved prediction of transplant outcomes.
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Affiliation(s)
- Gloria Chen
- Transplant Center, Memorial Hermann Hospital, Houston, TX, USA
| | - Cynthia S. Bell
- Department of Pediatric Nephrology and Hypertension, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | | | - Bashar Ibeche
- Department of Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - John S. Bynon
- Department of Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - David R. Hall
- Department of Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Aleksandra De Golovine
- Department of Internal Medicine, Renal Diseases and Hypertension, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Angelina Edwards
- Department of Internal Medicine, Renal Diseases and Hypertension, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Wasim A. Dar
- Department of Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
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8
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Yagil Y, Geller S, Levy S, Sidi Y, Aharoni S. Body-image, quality of life and psychological distress: a comparison between kidney transplant patients and a matching healthy sample. PSYCHOL HEALTH MED 2017; 23:424-433. [PMID: 29139313 DOI: 10.1080/13548506.2017.1400668] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The purpose of the current study was to assess the uniqueness of the condition of kidney transplant recipients in comparison to a sample of matching healthy peers in relation to body-image dissatisfaction and identification, quality of life and psychological distress. Participants were 45 kidney transplant recipients who were under follow-up care at a Transplant Unit of a major Medical Center, and a sample of 45 matching healthy peers. Measures were taken using self-report questionnaires [Body-Image Ideals Questionnaire (BIIQ), Body Identification Questionnaire (BIQ), Brief Symptoms Inventory (BSI), and the SF-12]. The major findings were the following: (i) kidney transplant recipients reported lower levels of quality of life and higher levels of PsD when compared to their healthy peers; (ii) no difference in body-image dissatisfaction was found between the two studied groups; (iii) significant correlations between body-image dissatisfaction quality of life and PsD were found only in the kidney transplant recipients. The kidney transplantation condition has a moderating effect in the association between body-image dissatisfaction PsD but not in the association between body-image dissatisfaction and quality of life; (iv) kidney transplant recipients experienced higher levels of body identification than did their healthy peers. Taken together, these findings highlight the unique condition of kidney transplant recipients, as well as the function that body-image plays within the self.
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Affiliation(s)
- Yaron Yagil
- a Department of Social Work , Tel-Hai College , Upper Galillee , Israel
| | - Shulamit Geller
- b School of Behavioral Sciences , Tel Aviv-Yaffo Academic College , Tel-Aviv , Israel
| | - Sigal Levy
- b School of Behavioral Sciences , Tel Aviv-Yaffo Academic College , Tel-Aviv , Israel
| | - Yael Sidi
- b School of Behavioral Sciences , Tel Aviv-Yaffo Academic College , Tel-Aviv , Israel
| | - Shiri Aharoni
- b School of Behavioral Sciences , Tel Aviv-Yaffo Academic College , Tel-Aviv , Israel
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9
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Pisanti R, Lombardo C, Luszczynska A, Poli L, Bennardi L, Giordanengo L, Berloco PB, Violani C. Appraisal of transplant-related stressors, coping strategies, and psychosocial adjustment following kidney transplantation. Stress Health 2017; 33:437-447. [PMID: 27862894 DOI: 10.1002/smi.2727] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 09/06/2016] [Accepted: 09/30/2016] [Indexed: 12/28/2022]
Abstract
This study examined the relations between appraisal of transplant-related stressors, coping, and adjustment dimensions following kidney transplantation (KT). Two models were tested: (1) the main effects model proposing that stress appraisal and coping strategies are directly associated with adjustment dimensions; and (2) the moderating model of stress proposing that each coping strategy interacts with stress appraisal. Importantly, there is a lack of research examining the two models simultaneously among recipients of solid organ transplantation. A total of 174 KT recipients completed the questionnaires. Predictors of post-transplant adjustment included appraisal of transplant-related stressors and coping strategies (task-, emotion-, and avoidance-focused). Adjustment dimensions were psychological distress, worries about the transplant, feelings of guilt, fear of disclosure of transplant, adherence, and responsibility for the functioning of the new organ. The main and moderating effects were tested with regression analyses. Appraisal of transplant-related stressors and emotion-oriented coping were related to all adjustment dimensions, except of adherence and responsibility. Task-oriented coping was positively related to responsibility. Avoidance-oriented coping was negatively correlated with adherence. Only 1 out of 18 hypothesized interactive terms was significant, yielding a synergistic interaction between appraisal of transplant-related stressors and emotion-oriented coping on the sense of guilt. The findings have the potential to inform interventions promoting psychosocial adjustment among KT recipients.
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Affiliation(s)
- Renato Pisanti
- Faculty of Psychology, University Niccolò Cusano, Rome, Italy
| | | | - Aleksandra Luszczynska
- SWPS University of Social Sciences and Humanities, Warsaw, Poland.,Trauma, Health, & Hazards Center, University of Colorado, Colorado, USA
| | - Luca Poli
- Sapienza University of Rome, Organ Transplant Unit Paride Stefanini, Rome, Italy
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Kähkönen O, Kankkunen P, Miettinen H, Lamidi ML, Saaranen T. Perceived social support following percutaneous coronary intervention is a crucial factor in patients with coronary heart disease. J Clin Nurs 2016; 26:1264-1280. [DOI: 10.1111/jocn.13527] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2016] [Indexed: 12/21/2022]
Affiliation(s)
- Outi Kähkönen
- Department of Nursing Science; University of Eastern Finland; Kuopio Finland
| | - Päivi Kankkunen
- Department of Nursing Science; University of Eastern Finland; Kuopio Finland
| | | | - Marja-Leena Lamidi
- Faculty of Health Sciences; University of Eastern Finland; Kuopio Finland
| | - Terhi Saaranen
- Department of Nursing Science; University of Eastern Finland; Kuopio Finland
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