Introduction

Chronic kidney disease (CKD) is a serious health problem that is common all over the world and its prevalence is increasing as the years progress. According to the report published by the U.S. Department of Health and Human Services, the prevalence of CKD was 13.3% between 2005-2008, 12.5% between 2009-2012, 13.9% between 2013-2016 and 14% between 2017-2020 (1). It is seen that hemodialysis is frequently used in the replacement treatment of chronic renal failure (2). According to 2016 data, there were 75,000 patients who underwent dialysis or kidney transplantation in our country (3). Cervantes et al. (4) found that the average 5-year relative risk of death for undocumented immigrants undergoing emergency hemodialysis was more than 14 times higher than those receiving standard hemodialysis.

There has been a great increase in the number of refugees coming to our country due to the increasing war, conflict and political reasons in the world, especially since 2011 (5). Syrians constitute the largest share in the number of refugees in Turkey. The official number of Syrians announced in November 2022 in our country is 3,577,714 people (6). Syrians are in temporary protection status in our country and their health expenses are covered by our country (7). However, studies have shown that although health expenditures are covered by our country, Syrians have some difficulties in accessing health services (8,9). The aim of hemodialysis treatment should be to provide self-care as well as medical treatment of patients (10). Self-care is activities initiated and performed by individuals themselves to maintain life, health and well-being. Self-care agency is the individual’s ability to initiate or implement health activities to maintain his or her life, health and well-being (11).

When we look at the literature, there are many studies that study refugees undergoing hemodialysis (12-14). However, there has not been any study evaluating the self-care abilities of the refugee and native populations receiving chronic hemodialysis, and it is thought to contribute to the literature.

Methods

Study Design

The study was descriptive and cross-sectional.

Sample of the Research

The sample of the study consisted of 33 refugee and 48 native hemodialysis patients aged 18 and over who accepted to undergo hemodialysis in the dialysis unit of a training and research hospital in Turkey. Participants aged 18 and over who voluntarily agreed to participate in the study were informed about the research and their rights, and their “informed consent” was obtained before the research. All the rights of the participants were respected and the principles of voluntariness and confidentiality were paid attention to.

Data Collection Method

Data were collected by face-to-face survey method between 02 March-15 March 2023. While collecting the questionnaires of the refugees, support was obtained from the translator of the hospital.

Data Collection

While collecting the data, a form describing the personal characteristics of the patients and the Self-Care Agency Scale (SCAS) for Chronic Hemodialysis Patients were used.

Personal Data Identification Form of Patients

The data was created by scanning the literature and consisted of 7 items related to age, gender, educational status, marital status, definition of refugee and native population, years on hemodialysis and years the refugees lived in Turkey.

Self-care Agency Scale for Chronic Hemodialysis Patients

The SCAS was developed by Ören and Enç (15) in 2010 and its validity and reliability study in Turkish was performed. In Ören and Enç (15) study, it was stated that Cronbach’s alpha values were between 0.56 and 0.68 on the basis of sub-dimensions and 0.75 in the whole scale. SCAS consists of 22 items. It is a three-point Likert scale scored between 0 and 2. The statements in the scale consist of 5 sub-dimensions related to the use of drugs, diet, self-monitoring of the patient, hygienic care and mental state. Low scores obtained from the scale are considered as poor self-care agency, and high scores are considered good (15). In this study, the Cronbach’s alpha coefficient of SCAS was determined as 0.72.

Statistical Analysis

IBM SPSS statistics 22.0 program was used for statistical analysis in the study. While evaluating the study data, in addition to descriptive statistical methods (mean, standard deviation, frequency, percent), the Student t-test was used to compare normally distributed data, and the Mann-Whitney U test was used to compare data that did not show normal distribution. Pearson and Spearman correlation analyses were used to evaluate the correlation between variables. The results were evaluated at the 95% confidence interval and the significance level of p<0.05.

Ethical aspect of the study: Before starting the study, permission was obtained from the Clinical Research Ethics Committee of University of Health Sciences Turkey, İstanbul Haseki Training and Research Hospital with the date of 01.03.2023 and the decision number 06-2023. Permission was also obtained from the scale’s authors. Participants who voluntarily accepted to participate in the study were informed about the research and their rights as necessary, and their “informed consent” was obtained before the research. All the rights of the participants were respected and the principles of voluntariness and confidentiality were paid attention to.

Results

The descriptive characteristics of the refugee and native populations in chronic hemodialysis patients are shown in Table 1. It was determined that 51.5% of the refugee population of the participants were women, 87.9% were married, 27.2% had primary school education, average age was 49.06±15.68, the number of years that refugees lived in Turkey was 6.65±2.51 years in Turkey, and they had undergone hemodialysis for 33.93±21.93 months. On the other hand, 60.4% of the native population were male, 77.1% were married, 45.8% had primary school education, mean age was 54.54±16.76 and they had undergone hemodialysis for 23.84±23.08 months (Table 1).

Table 2 shows whether there is a significant difference between the two populations in the mean scores and mean scores of SCAS and its sub-dimensions applied to the refugee and native populations in chronic hemodialysis patients. Although there was no significant difference between the two populations in terms of the total scores of self-care agency (p=0.768, p<0.05), a significant difference was found between the groups in terms of drug use (p=0.041, p<0.05) and self-monitoring (p=0.048, p<0.05), which were sub-dimensions of SCAS (Table 2).

In chronic hemodialysis patients, the correlation between the sub-dimensions of self-care ageny in the refugee and native populations and the years the refugees lived in Turkey and the months both groups had been on hemodialysis was examined (Table 3). There was no significant correlation between the sub-dimensions of the scale and the months of undergoing dialysis and the years they lived in Turkey (p<0.05) (Table 3).

Discussion

Correlation findings between the descriptive characteristics of the refugee and native populations in chronic hemodialysis patients (Table 1), the total scores and sub-dimensions scores obtained from SCAS its (Table 2), the years they lived in Turkey and the months they were on dialysis (Table 2) were given (Table 3). When we look at the literature, no study has been found that compares the self-care agency of refugee and native populations in chronic hemodialysis patients. The findings of the study will be compared with the self-care agency scores of the patients identified in the literature. In the study conducted by Aydın and Sayılan (16) on 125 patients aged 65 and over, the mean self care agency score was 90.00±19.95 [maximum (max) score: 140], and in the randomized controlled study conducted by Deveci and Aydın (17) on 70 hemodialysis patients, it was determined that the mean self care agency score of the intervention group (n=35) was 86.20±16.00, and the mean self care agency score of the control group (n=35) was 79.11±14.65 (max: 136 points). In the study conducted by Du et al. (18) on 472 elderly patients in China, it was 106.12±19.47 (max: 172 points), while in the study conducted by Demir Gökmen and Fırat (19) on 146 patients with COPD, it was 73.09±14.153 (max: 140 points) (and in the study conducted by Türker et al. (20) on 126 hemodialysis patients, it was found to be 51.01±27.33 (max: 134 points). In this study, SCAS score of the refugee population was determined as 28.91±4.68, and SCAS score of the native population was 28.52±6.44 (max: 44 points). When the studies in the literature and the self-care measurement tools used in those study were examined, it was seen that different self-care agency scales were used, and their maximum mean scores were different. When the mean scores of self-care agency were evaluated with the scale of each study, it was determined that the mean score of self-care agency was moderate. In this direction, when the results of the studies in the literature were compared with this study, it was seen that the results of the literature supported the results found in this study.

In the study, no significant relationship was found between the refugee and native populations in terms of both the mean scores of self-care agency (p=0.768) (Table 2), the scale sub-dimensions of both groups, the months of undergoing dialysis and the years they lived in Turkey (Table 3). Although it has been determined in the literature studies that refugees have difficulties in accessing health services, the findings of the study show that refugees receive services in the same way as the native population (8,9). The reason for the difference from the literature might be that hemodialysis patients constituted the sample group in the study, and when it was considered that the patients would die when hemodialysis treatment was not performed, it could be considered that patients’ reach to treatment was mandatory.

In the study, it was determined that there was a significant difference between the refugee and native populations in terms of the sub-dimensions of SCAS, use of drugs (p=0.041, p<0.05) and self-monitoring (p=0.048, p<0.05) (Table 2). Drug use was found to be higher in the native population than in the refugees. In studies conducted in our country, it has been stated that refugees have language problems (21-23). Drug use, which is the sub-dimension of self-care agency, is proportional to the success of the education given to the patient (24). When the patient cannot receive adequate education due to language problems, they may be insufficient in their drug use. Refugees’ self-monitoring was found to be higher than the native population. Considering the ages of the refugees and the native population (Table 1), it was seen that the average age of the refugees was 49.06±15.68, while the average age of the native population was 54.54±16.76, and it was seen that the refugees were younger. The fact that the self-monitoring of refugees is higher than the native population can be attributed to the fact that they are younger. The limitations of our study were the small number of patients and the fact that the study was conducted in a single center.

Conclusion

As a result, the status of meeting self-care in the refugee and native populations is the same in chronic hemodialysis patients, while the refugees are inadequate in drug use and the native population in self-monitoring. We think that support from a hospital translator should be sought in order to reduce language problems while providing self-care training to refugees, and that more clear results can be achieved in future through multicenter studies with larger samples.

Ethics

Ethics Committee Approval: Before starting the study, permission was obtained from the Clinical Research Ethics Committee of University of Health Sciences Turkey, İstanbul Haseki Training and Research Hospital with the date of 01.03.2023 and the decision number 06-2023.

Informed Consent: Permission was also obtained from the scale’s authors.

Peer-review: Externally peer reviewed.

Authorship Contributions

Surgical and Medical Practices: N.K., E.C., A.Ş., Concept: N.K., E.C., Design: N.K., E.C., İ.Ç., Data Collection or Processing: N.K., İ.Ç., A.Ş., Analysis or Interpretation: N.K., Literature Search: N.K., M.R., Writing: N.K., M.R.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.