https://doi.org/10.15218/ejnm.2021.01 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article Dialysis-Related Factors Affecting Activities of Daily Living among Hemo- dialysis Patients in Erbil City ABSTRACT INTRODUCTION Dialysis is the best technique to remove excess fluid and waste products from the body if the kidneys cannot perform this function. It can also balance acid-base and regulate fluid and electrolytes [1].The he- modialysis machine (HD) filters and cleans the blood of the patients, usually three times per week, four to six hours at A time [2]. Daily activities like self-care of an individual at home and other individual activities outdoors are called Activities of Daily Living (ADLs). Ability and inability of doing ADLs is an essential measure of the functional status of individual patients [3].Main types of ADLs are self-care activi- ties such as eating, personal hygiene, Background and objectives: Hemodialysis procedure is one of the important replacement therapies for patients with renal failure. Maintenance hemodialysis is associated with many complications that play a significant role in the activities of daily living. The present study aimed to find out the factors affecting activities of daily living among patients with maintenance hemodialysis in Erbil City in the Kurdistan Region of Iraq. Methods: The cross-sectional study was conducted on 268 patients undergoing mainte- nance hemodialysis for more than two months, and at least two times per a week at two dialysis centres in Erbil City from December 2019 to April 2020. The activities of daily living and complications from the hemodialysis procedure questionnaire to collect research da- ta. The data analysis was conducted using descriptive statistical approach including fre- quency, percentages, and inferential statistical analysis consisting chi-square test. Results: According to the findings of the study, the majority of participants were above 51 years of age, able to read and write, with middle income, and from an urban area. Almost half of the study sample were males, and most were on hemodialysis between one and three years. The majority of them had hypertension and complications associated with he- modialysis such as headache and hypotension, and more than half had back pain. A highly significant association was found between dependency in activities of daily living and some socio-economic and clinical variables. Furthermore, a significant association was found be- tween dependency in activities of daily living and some hemodialysis complications with P<0.001. Conclusion: According to the result of the study, the researchers concluded that partici- pants suffered from chronic diseases, hemodialysis complications and low level of activities of daily living. The complications of hemodialysis treatment were significantly affecting the activities of daily living. Haemodialysis patients need more education and nursing care to reduce treatment complications and to increase their activities. Keywords: Activities; Daily living; Hemodialysis patient; Complication; Independency; De- pendency. Sideeq Sadir Ali; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: sideeq.ali@hmu.edu.krd) Vian Afan Naqshbandi; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. Shihab Ahmed Sedeeq ; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. 1 Erbil Journal of Nursing & Midwifery Received: 27/05/2020 Accepted: 08/11/2020 Published: 30/05/2021 mailto:sideeq.ali@hmu.edu.krd https://doi.org/10.15218/ejnm.2021.01 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article shopping and mobility [4].Treatment by HD always needs to be done at an HD centre or a hospital because the patients may de- velop many complications [5]. A study by Kopple et al. (2018) reported that patients with maintenance HD had reduced perfor- mance of physical mobility and daily physi- cal activity [6]. Another study that was con- ducted on physical activity of HD patients revealed that their physical activity was lower than other patients, because of many problems, complications and stress- ful factors related to the condition and treatment [7]. It is essential to assess and monitor the level of physical activities of all HD patients, especially during the day of HD procedure because they often deal with several problems related to their sedentary lifestyle [8]. The patients should improve their daily activity and self-care to prevent HD complications and to continue the life of health and well-being [9].The research- ers assessed the patients' level of ADLs and determined the main complications and problems that occurred during and after HD. They also identified the main related factors that affected those problems and inactivity. The cross-sectional study design was con- ducted at both Dialysis Centers of Hawler Teaching Hospital in Erbil City in the Kurdi- stan Region of Iraq. The study sample in- cluded all patients with maintenance he- modialysis treatment in both Centers. From 318 HD patients treated in the cen- tres, 268 patients were selected according to the inclusion criteria of the present study. The inclusion criteria encompassed all male and female patients above the age of 18 with chronic renal failure and maintenance HD at least twice a week. Fifty cases were excluded; 12 were under 18 years old, 10 were on HD less than two months, 13 had HD treatment less than one time a week, and 15 refused to partici- pate in the study. The study was conduct- ed during the period of 1st December 2019 to 15th April 2020. The data were collected during one month after approval of the proposal. The researchers collected the data by face to face interviews using a questionnaire, which consisted of three parts based on the proposed research ob- jectives. Part 1 included socio- demographic datasheet; part 2 contained clinical information, and part 3 recorded HD complications that the researchers identified through the literature review. Part 4 was used to assess the ADLs. The concept of the ADLs was first described by Sheldon in the Journal of Health and Physi- cal Education in 1935, as reported by Fein- stein et al.[10]. In 1969, Lawton and Brody were the first authors to describe two lev- els of ADLs as basic and instrumental ADLs, and they considered it to be a valid and reliable scale for health surveys [11]. The ADLs tool was used in many studies such as Singh et al., in 2007, Watanabe et al., in 2018 and Kutsuna et al., in 2019 [12,13,14]. The researchers modified the ADLs tool to achieve the research objec- tives and included 16 items divided into two domains subscales; basic ADLs (10 items), instrumental ADLs (6 items) and 3 levels of ADLs dependency (independent, requires assistance and dependent). The study was approved by the Scientific and Ethical Committees at the College of Nurs- ing of Hawler Medical University in Erbil. The verbal consent was obtained from each patient with HD before the interview. The data were analysed using the Statisti- cal Package for Social Sciences (SPSS, Ver- sion 25), and used two statistical ap- proaches. The descriptive data analysis in- cluded frequency and percentage, and in- ferential data analysis calculated Chi- square test. P-value of ≤ 0.05 was consid- ered statistically significant to find out 2 Erbil Journal of Nursing & Midwifery METHODS https://doi.org/10.15218/ejnm.2021.01 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article Most of the patients (89.6%) had other chronic diseases ( 73.9% hypertension, 49.3% diabetes mellitus, 14.6% anaemia, 14.2% heart disease and 3.7% hepatitis). Regarding the duration of HD treatment, more than half of the participants (55.2%) received treatment for 1-3 years. A high percentage of them (94.8%) had infor- mation about the importance of ADLs. Ta- ble 3 demonstrates the overall activities of daily living divided into two main domains, basic and instrumental activities. The maxi- mum percentage of basic ADLs (42.9%) was within the level of independence. However, more than half (52.6%) of the participants were dependent in the instru- mental ADLs. In general, the largest pro- portion of participants (36.6%) was within the level of dependency in both types of ADLs (basic and instrumental). factors that affected daily ADLs among HD patients. Regarding the scoring, 0 was used for 'dependent', 1 for 'requires assistance' and 2 for 'independent' responses. An overall level of ADLs was also determined as ‘independent’, ‘requires assistance’ and ‘dependent’. Table 1 shows the socio-economic charac- teristics of HD patients. Most participants were more than 51 years old (68.3%), male (51.5%) and illiterate (61.2%). Moreover, the majority of the patients were married (70.2%), and 45.9% were housewives, had middle income (76.9%) and lived in urban areas (89.2%).Table 2 shows the clinical characteristics of the participants. Almost half of the patients (47.8%) who took part in the study had a normal weight. 3 Erbil Journal of Nursing & Midwifery RESULTS Table 1: Socio-economic data of patients with maintenance hemodialysis n= 268 F (%) Age group (years) 18-35 28 (10.4) 36-50 57 (21.3) 51 and above 183 (68.3) Sex Male 138 (51.5) Female 130 (48.5) Formal years of education Read and/write 164 (61.2) Primary school 71 (26.4) Secondary 9 (3.4) Higher Educa- 24 (9) Marital sta- tus Single 18 (6.7) Married 188 (70.2) Widower 62 (23.1) Current occu- pation Employment 25 (9.3) Jobless 120 (44.8) Housewife 123 (45.9) Economic Status Low income 33 (12.3) Middle income 206 (76.9) High income 29 (10.8) Residential Urban 239 (89.2) Rural 29 (10.8) Table 2: Clinical characteristic of the pa- tients with maintenance hemodialysis Variables n= 268 F (%) Body Max Index (BMI) Underweight 10 (3.7) Normal Weight 128 (47.8) Overweight 88 (32.8) Obese 42 (15.7) Associated dis- ease with chronic Renal Failure Yes 240 (89.6) No 28 (10.4) Type of chronic disease (n= 240) Hypertension 198 (73.9) Diabetes Mellitus 132 (49.3) Anaemia 39 (14.6) Heart Disease 38 (14.2) Hepatitis 10 (3.7) Duration of HD treatment <1 year 56 (20.9) 1–3 years 148 (55.2) >3 year 64 (23.9) Information about ADL Yes 254 (94.8) No 14 (5.2) https://doi.org/10.15218/ejnm.2021.01 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article Table 4 exhibits the common complications and problems that occurred during and after the HD procedure. The most common complications identified through the ques- tionnaire included headache (81.7%) after HD procedure (39.9%), hypotension (72%) during HD procedure (59.3%) and back pain (58.2%) during HD procedure (43.3%). The least common problems and complications that occurred among HD patients included infiltration (4 cases, 1.5%) during HD proce- dure in all 4 patients (100%), air embolism (4 cases, 1.5%), 3 cases occurred during HD procedure (1.1%), and the least common complication was coma in 5 patients (1.7%), 4 (1.5%) of which occurred during HD procedure. Table 5 demonstrates the association between the ADLs and socio- economic characteristics of the patients. There was a highly significant association between the 'dependent' level of the ADLs and four variables; age group of the partici- pants (46.1% for 56 years and above and 14% for 36 - 55 years vs 10.7% for 18 - 35 years, P-value <0.001), marital status (61.3% for a widower and 23.9% for mar- ried vs 16.7% for single, P-value <0.001), formal years of education (41.5% for illit- erate and can read/ write and 19.7% for primary school graduates vs 16.7% for higher-level education, P-value <0.001), and current occupation (39.8% for house- wife and 29.2% for unemployment vs 8% for employment, P-value <0.001). Dependency was more significant among low income and middle-income partici- pants than in high-income respondents (36.4% and 34%, 13.8% respectively, P = 0.025). Finally, there was no significant as- sociation between the ADLs and gender (P = 0.057) and residential area (P = 0.221). Table 6 shows the association between clinical characteristics and ADLs. Depend- ency of ADLs was significantly associated with the BMI (50% for underweight, 35.2% for normal weight, 27.3% overweight and 28.6% for obese, P-value = 0.020) and du- ration of HD treatment (33.9 % for <1 year and 31.8% for 1–3 years vs 31.3% for >3 year, P-value =0.037). Also, dependency was significantly associated with another chronic disease; hypertension (35.4% hy- pertension and 22.9% for no hypertension, P-value = 0.004), diabetes mellitus (41.7% diabetes mellitus and 22.8% for no diabe- tes mellitus, P-value = 0.002), hepatitis (32.9% for no hepatitis and 29.1%, for hep- atitis, P-value = 0.029) and heart disease (50% heart disease and 29.1% for no heart disease, P-value = 0.003). Finally, depend- ency was significantly associated with not being informed about ADLs (35.7%) and 31.9% and being informed about ADLs (31.9%) (P-value = 0.006). There was no statistically significant association between ADLs and anemia (P-value = 0.062).Final results of the study are demonstrated in Table 7. They illustrate an association be- tween some complications and problems of the HD procedure and overall level of ADLs. From all of 19 complications/ prob- lems, only nine had a statistically signifi- cant association with ADLs. The dependent level of the ADLs was significantly higher in patients with nausea (44.4% nausea vs. 29% no nausea, P = 0.004), vomiting (42.3% vomiting vs. 28.4% no vomiting, P = 0.021), restlessness (37.3% no restlessness vs. 29.2% restlessness, P = 0.041),tightness 4 Erbil Journal of Nursing & Midwifery Table 3: Overall Activities of Daily Living items Activities of Daily Living Dependent Requires assistance Independent F (%) F (%) F (%) Basic Activity 82 (30.6) 71 (26.5) 115 (42.9) Instrumental Activity 141 (52.6) 90 (33.6) 37 (13.8) Overall ADLs 98 (36.6) 86 (32.1) 84 (31.3) https://doi.org/10.15218/ejnm.2021.01 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article 28.7% no clotting, P = 0.043), blood line obstruction (80% blood line obstruction vs. 30.2% no blood line obstruction, P = 0.004) and hematoma (33.1% no hematoma vs. 0% hematoma, P = 0.003). 5 Erbil Journal of Nursing & Midwifery in the chest (37.2% no tightness in the chest vs. 27.8% tightness in the chest, P = 0.003), chills (32.9% no chills vs. 29.1% chills, P = 0.049), fever (38.2% no fever vs. 27.9% fever, P = 0.026), clotting (38.1% clotting vs. Table 4: Health problems associated with hemodialysis among the study sample Complication or Problem No Yes Yes During proce- dure After proce- dure Remaining by hours F (%) F (%) F (%) F (%) F (%) Nausea 214 (79.9) 54 (20.1) 48 (17.9) 5 (1.9) 1 (0.4) Vomiting 197 (73.5) 71 (26.5) 63 (23.5) 7 (2.6) 1 (0.4) Restlessness 244 (91) 24 (9) 19 (7.1) 4 (1.5) 1 (0.4) Headache 49 (18.3) 219 (81.7) 95 (35.4) 107 (39.9) 17 (6.3) Seizure 258 (96.3) 10 (3.7) 5 (1.9) 5 (1.9) 0 (0) Coma 263 (98.1) 5 (1.9) 4 (1.5) 1 (0.4) 0 (0) Hypotension 75 (28) 193 (72) 159 (59.3) 29 (10.8) 5 (1.9) Back pain 112 (41.8) 156 (58.2) 116 (43.3) 26 (9.7) 14 (5.2) Tightness in the chest 250 (93.3) 18 (6.7) 11 (4.1) 5 (1.9) 2 (0.7) Shortness of breath 215 (80.2) 53 (19.8) 44 (16.4) 8 (3) 1 (0.4) Chill 213 (79.5) 55 (20.5) 46 (17.2) 6 (2.2) 3 (1.1) Fever 225 (84) 43 (16) 34 (12.7) 8 (3) 1 (0.4) Air embolism 264 (98.5) 4 (1.5) 3 (1.1) 1 (0.4) 0 (0) Clotting 171 (63.8) 97 (36.2) 92 (34.3) 4 (1.5) 1 (0.4) Blood line ob- struction 258 (96.3) 10 (3.7) 10 (3.7) 0 (0) 0 (0) Bleeding 249 (92.9) 19 (7.1) 14 (5.2) 5 (1.9) 0 (0) Pain 231 (86.2) 37 (13.8) 31 (11.6) 4 (1.5) 2 (0.7) Infiltration 264 (98.5) 4 (1.5) 4 (100) 0 (0) 0 (0) Hematoma 260 (97) 8 (3) 3 (37.5) 5 (62.5) 0 (0) https://doi.org/10.15218/ejnm.2021.01 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article 6 Erbil Journal of Nursing & Midwifery Table 5: Association between socio-economic data and overall ADLs Variables Dependent Requires assistance Independent P-Value F (%) F (%) F (%) Age group (year) 18 - 35 (Young Adult) 3 (10.7) 3 (10.7) 22 (78.6) <0.001 36 - 55 (Middle-Aged Adults) 12 (14) 18 (20.9) 56 (65.1) 56 years old and above (Older Adult) 71 (46.1) 62 (40.3) 21 (13.6) Sex Male 36 (26.1) 47 (34.1) 55 (39.9) 0.057 Female 50 (38.5) 36 (27.7) 44 (33.8) Marital Sta- tus Single 3 (16.7) 3 (16.7) 12 (66.7) <0.001 Married 45 (23.9) 60 (31.9) 83 (44.1) Widower 38 (61.3) 20 (32.3) 4 (6.5) Formal years of education Illiterate and Can read /write 68 (41.5) 58 (35.4) 38 (23.2) <0.001 Primary school 14 (19.7) 21 (29.6) 36 (50.7) Secondary school 0 (0) 3 (33.3) 6 (66.7) Higher Education 4 (16.7) 1 (4.2) 19 (79.2) Current oc- cupation Employment 2 (8) 2 (8) 21 (84) <0.001 Jobless 35 (29.2) 45 (37.5) 40 (33.3) Housewife 49 (39.8) 36 (29.3) 38 (30.9) Economic status Low income 12 (36.4) 13 (39.4) 8 (24.2) 0.025 Middle income 70 (34) 63 (30.6) 73 (35.4) High income 4 (13.8) 7 (24.1) 18 (62.1) Residential area Urban 74 (31) 73 (30.5) 92 (38.5) 0.221 Rural 12 (41.4) 10 (34.5) 7 (24.1) https://doi.org/10.15218/ejnm.2021.01 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article 7 Erbil Journal of Nursing & Midwifery Table 6: Association between clinical data and the overall level of ADLs Variables Dependent F (%) Requires as- sistance F (%) Independent F (%) P-Value Classification of BMI Underweight 5 (50) 0 (0) 5 (50) 0.020 Normal Weight 45 (35.2) 31 (24.2) 52 (40.6) Overweight 24 (27.3) 39 (44.3) 25 (28.4) Obese 12 (28.6) 13 (31) 17 (40.5) Duration of HD treatment <1 year 19 (33.9) 16 (28.6) 21 (37.5) 0.037 1–3 years 47 (31.8) 38 (25.7) 63 (42.6) >3 year 20 (31.3) 29 (45.3) 15 (23.4) Do you have hyper- tension? Yes 70 (35.4) 66 (33.3) 62 (31.3) 0.006 No 16 (22.9) 17 (24.3) 37 (52.9) Do you have Diabe- tes Mellitus? Yes 55 (41.7) 39 (29.5) 38 (28.8) 0.002 No 31 (22.8) 44 (32.4) 61 (44.9) Do you have anae- mia Yes 17 (43.6) 14 (35.9) 8 (20.5) 0.062 No 69 (30.1) 69 (30.1) 91 (39.7) Do you have hepati- tis? Yes 1 (10) 5 (50) 4 (40) 0.029 No 85 (32.9) 78 (30.2) 95 (36.8) Do you have heart disease? Yes 19 (50) 12 (31.6) 7 (18.4) 0.003 No 67 (29.1) 71 (30.9) 92 (40) Do you have infor- mation about ADLs Yes 81 (31.9) 80 (31.5) 93 (36.6) 0.006 No 5 (35.7) 3 (21.4) 6 (42.9) https://doi.org/10.15218/ejnm.2021.01 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article 8 Erbil Journal of Nursing & Midwifery Table 7: Association between overall ADLs and complications/ problems Complications/ Problems Overall ADL levels P-Value Dependent Requires assis- tance Independent F (%) F (%) F (%) Nausea (*yes =54) (*no =214) Yes 24 (44.4) 10 (18.5) 20 (37) 0.004 No 62 (29) 73 (34.1) 79 (36.9) Vomiting (*yes =71) (*no=197) Yes 30 (42.3) 20 (28.2) 21 (29.6) 0.021 No 56 (28.4) 63 (32) 78 (39.6) Restlessness (*yes = 219) (*no= 49) Yes 7 (29.2) 13 (54.2) 4 (16.7) 0.041 No 91 (37.3) 73 (29.9) 80 (32.8) Headache (*yes = 219) (*no= 49) Yes 21 (42.9) 9 (18.4) 19 (38.8) 0.071 No 65 (29.7) 74 (33.8) 80 (36.5) Hypotension (*yes = 193) (*no= 75) Yes 62 (32.1) 58 (30.1) 73 (37.8) 0.215 No 24 (32) 25 (33.3) 26 (34.7) Back pain (*yes = 156) (*no= 112) Yes 55 (35.3) 50 (32.1) 51 (32.7) 0.101 No 31 (27.7) 33 (29.5) 48 (42.9) Tightness in the Chest (*yes = 18) (*no= 250) Yes 5 (27.8) 12 (66.7) 1 (5.6) 0.003 No 93 (37.2) 74 (29.6) 83 (33.2) Chill (*yes = 55) (*no= 213) Yes 16 (29.1) 15 (27.3) 24 (43.6) 0.049 No 70 (32.9) 68 (31.9) 75 (35.2) Fever (*yes = 43) (*no= 225) Yes 12 (27.9) 10 (23.3) 21 (48.8) 0.026 No 86 (38.2) 76 (33.8) 63 (28) Clotting (*yes = 97) (*no = 171) Yes 37 (38.1) 34 (35.1) 26 (26.8) 0.043 No 49 (28.7) 49 (28.7) 73 (42.7) Blood line obstruc- tion (*yes =10) (*no= 258) Yes 8 (80) 0 (0) 2 (20) 0.004 No 78 (30.2) 83 (32.2) 97 (37.6) Hematoma (*yes = 8) (*no= 260) Yes 0 (0) 6 (75) 2 (25) 0.003 No 86 (33.1) 77 (29.6) 97 (37.3) https://doi.org/10.15218/ejnm.2021.01 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article only 30% of participants were independent in ADLs, while post-intervention, 50% were independent, demonstrating an increased by two-thirds. 66.7% of patients in the study were independent after the follow- up period [21].The treatment by HD proce- dure among patients in this study was as- sociated with many complications and problems. The majority of patients had headache, hypotension and back pain. At the same time, the least common compli- cation was a coma, and the least common problems were infiltration and air embo- lism that occurred during the HD proce- dure. Those complications or problems were expected as the majority of the study participants had other chronic diseases, and those complications could be due to those conditions. Moreover, the HD proce- dure is the major invasive procedure that transports the blood from the body of the patients into the dialyser machine through the hollow fibres, and after the filtration returns into the body, which takes 4 to 6 hours. Therefore the HD procedure carries the risk of many complications [22]. The HD patients experience multiple problems and health complications in the communi- ty and their daily lives because they have daily treatment as well as the treatment by hemodialysis procedure [23, 24]. The re- sults of this study were supported by the Caplin et al., study that studied 550 HD pa- tients in London, UK. After analysis, they identified the hypotension, headache, backache, pruritus, dizziness and cramps as the main complications of HD [25]. An- other retrospective study in the Uttar Pra- desh, India; during 11 years assessed 2325 renal failure HD patients and found that the most common intradialytic complica- tions were hypotension, nausea, vomiting, fever and chills [26]. The cross-sectional survey study by Gela and Mengistu con- ducted in Ethiopia showed that the majori- ty of the participants on HD treatment This study explored the common compli- cations and problems associated with HD during or after the procedure and factors that affected patients' ADLs. The results revealed that almost half of the partici- pants were dependent in performing in- strumental ADLs. In contrast, the maxi- mum percentage of participants were independent in their basic ADLs. The overall level of patients' independence in ADLs was inadequate. According to ex- tensive research data, the activity during the day is essential for all people and es- pecially for patients with chronic kidney disease. In contrast, inactivity is one of the main problems associated with many diseases, complications and mortality as well as the quality of life [15, 16, 17]. The results of low activity in our study could be due to the age of the study partici- pants as the majority of them were more than 51 years old. Low level of education could also contribute, as the activity in the older age group usually declines in the society. This result is supported by the study of Julius et al., which reported the highest dependency in ADLs among older patients, female and less educated [18]. Painter and Marcus found that, gen- erally, participants with renal failure usu- ally had low levels of physical activity [19]. The study of Cook and Jassal also supported this result; the majority of their study group was dependent in most items of basic and instrumental ADLs [20]. Self-care activities can increase if they are designed by educational pro- gram and improve patients' knowledge, as found in the quasi-experimental study of Mohamed et al., which was conducted in Egypt. It used Nottingham scale of ADLs and studied the effect of the inter- ventional program on the HD patients and their ability of self-care. The results showed that before the intervention, 9 Erbil Journal of Nursing & Midwifery DISCUSSIONS https://doi.org/10.15218/ejnm.2021.01 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article of studied patients was over one year, which may lead to unemployment and in- adequate income. All of the above chal- lenges also affected the psychology of the patients and their ADLs [32,33]. This result was supported by Aucella et al. in Italy, whose research concluded that unemployment and age of HD patients affected their activity, and education, du- ration of dialysis and presence of anaemia were also associated with a low level of energy [34]. This research also agrees with many other studies that showed that occu- pational status of HD patients was signifi- cantly associated with daily activity [35, 36, 37]. The effect of the duration of HD treat- ment on ADLs in the present study was different from a descriptive study on 138 HD patients in Sivas, Turkey, which found no significant association between the du- ration of HD and patients' activity [38]. In the present study, the ADLs were positive- ly associated with the income as in the study of Kamble and Shinde in India, in which the monthly income of the family was associated with physical activity [39]. The current study identified a highly signifi- cant association between marital status and ADLs as in the study by Julius et al.; in which dependency in ADLs was associated with the marital status and educational level [18]. Furthermore, the dependency in ADLs was significantly associated with the presence of another chronic disease. Thomas et al. in their study demonstrated that some of the chronic kidney diseases were significantly associated with many health complications like anaemia and car- diovascular disease [40]. The dependency in ADLs was significantly associated with some chronic disease like hypertension, diabetes mellitus, hepatitis and heart dis- ease in research by Algarni, in 2014, who stated that the diabetes mellitus and hy- pertension were the leading causes of re- nal failure and affected ADLs[41]. Had anaemia as acomplication [27]. He- modialysis patients often complain about many complications before, during and after HD treatment. By improving nursing interventions, nurses can reduce the risk of complications [28]. The present study identified infiltration and air embolism as problems related to vascular access. The longitudinal cohort study that was con- ducted in North America observing vas- cular HD access during 90 days and sec- ond time end of the first year revealed many problems [29]. The ADLs of pa- tients were significantly associated with many variables of socio-economic and clinical characteristic. There was a highly statistically significant association with age group, level of education and BMI of the participants, which could be because the majority of the study groups were older adults, and their level of education was low. Furthermore, almost half of the participants had a normal weight, howev- er, the daily accumulation of waste prod- ucts and excessive fluid led to an increase in their weight affecting their activity. These results are similar to the findings of a study by Johansen et al. in the Califor- nia, USA, which showed age, level of edu- cation, and BMI were significantly associ- ated with physical activity [30]. However, there was a difference with the study by Stack and Murthy, who found that severe limitations in the ADLs among HD pa- tients were negatively related to the age and heart failure [31]. The current occu- pation and economic status, as well as the duration of HD treatment of the pa- tients in the current study also affected the ADLs. This could be due to the high percentage of housewives and unem- ployed people in the study sample. Also, a majority of participants had middle in- come and were dependent on other peo- ple for daily income. Additionally, the duration of dialysis in the majority 10 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2021.01 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article with the dependency in ADLs. This result agrees with a study by Davenport, in 2006, which explored low functional activity among HD patients related to complica- tions of HD procedure such as chest tight- ness, angioedema with throat and larynge- al oedema fever, tachycardia, flushing, headache, chest pain, dyspnea, pruritus, anxiety, laryngeal oedema, numbness of the fingers toes and lips, hypotension and hypertension [50]. Moreover, this study was supported by Mehmood et al., who, in 2016, observed an association between complications during hemodialysis and ac- tivity like; hypotension, cramps, itching, vomiting and dialysis reaction [51]. This study found that the ADLs of hemodi- alysis patients were low, which could be due to the ageing process, low level of ed- ucation and the presence of other chronic diseases. The results of the study showed that there was a highly significant statisti- cal association between ADLs and the ma- jority of the socio-economic and clinical characteristics. Most patients suffered from complications and problems of HD during and after treatment, which in- creased their dependency in ADLs. Nursing care and patient education are essential for hemodialysis patients and can increase functional daily living activity and decrease in HD related complications and problems. The authors report no conflicts of interest. [1] Smeltzer SO, Bare BG. Brunner and Suddarth's Textbook of Medical-Surgical Nursing. 10th ed. Philadelphia: JB Lippincott; 2003. P. 1289. [2] Rhoades, RA, Tanner, GA. Medical Physiolo- gy. 2nd ed. Lippincott-Raven. Part VI Renal Physiology and Body Fluids, Chapter 23, Kid- ney Function; 2003. P.378. This result agrees with many studies that explored diabetes mellitus as the main factors of renal disease which also signifi- cantly affected daily activity [42, 43]. Concerning the association of ADLs with heart disease, this study is supported by a cross-sectional study by Cheung et al., in which the majority of HD patients had other cardiovascular diseases, and there was a positive association between activ- ity and all disease categories and age [44]. Another study similar to this re- search was by Mousa et al., in which the majority of study participants had a chronic disease, and activity of the pa- tients was significantly associated with age, educational level, income, living sta- tus, occupation, and HD duration [45].Further results of the current study illustrated that some of the HD complica- tions or/and problems occurred during or after HD procedure or continued for some time after. The HD procedure is invasive, difficult for the patient to cope with, and carries the risk for myocardial infarction, heart failure, fluid overload and stroke that can also affect ADLs[46]. Furthermore, there could be some hid- den problem such as coronary artery dis- ease, aplastic bone disease, high turno- ver renal bone disease, bleeding diathe- sis (uremic platelets), and osteomalacia, which can be directly associated with de- creased daily activity [47]. This is in agreement with the study of Alhajim, in 2017, found that HD patients often expe- rience many complications such as cardi- ovascular disease that directly affect their ADLs [48]. This study is also sup- ported by a descriptive and analytical study done in Iran by Asgari et al., which revealed that patients undergoing HD faced severe nausea and vomiting [49]. Another complication was restlessness and tightness in the chest, which were also significantly associated 11 Erbil Journal of Nursing & Midwifery CONCLUSION CONFLICTS OF INTEREST REFERENCES https://doi.org/10.15218/ejnm.2021.01 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article [13] Watanabe T, Kutsuna T, Yoneki K, Harada M, Shimoda T, Matsunaga Y, et al. Determinants of difficulty in activities of daily living in am- bulatory patients undergoing hemodialysis. Renal Replacement Therapy. 2018 Dec 1; 4 (1): 1-8. Available from: DOI 10.1186/ s41100-018-0146-y. [14] Kutsuna T, Isobe Y, Watanabe T, Matsunaga Y, Kusaka S, Kusumoto Y, et al. Comparison of difficulty with activities of daily living in elderly adults undergoing hemodialysis and community-dwelling individuals: a cross- sectional study. Renal Replacement Therapy. 2019 Dec 1; 5 (1):50. Available from: https://doi.org/10.1186/s4110-019-0250-7. [15] Jagannathan R, Ziolkowski SL, Weber MB, Cobb J, Pham N, Long J, et al. Physical activi- ty promotion for patients transitioning to dialysis using the “Exercise is Medicine” framework: a multi-centre randomised prag- matic trial (EIM-CKD trial) protocol. BMC Nephrology. 2018 Dec 1; 19 (1): 230. Availa- ble from: https://doi.org/10.1186/s12882- 018-1032-0. [16] Anding K, Bär T, Trojniak-Hennig J, Kuchinke S, Krause R, Rost JM, et al. A structured exer- cise programme during haemodialysis for patients with chronic kidney disease: clinical benefit and long-term adherence. BMJ Open. 2015 Aug 1; 5 (8):e008709. Available from: DOI:10.1136/bmjopen-2015-008709. [17] Kutner NG, Zhang R, Allman RM, Bowling CB. Correlates of ADL difficulty in a large hemo- dialysis cohort. Hemodialysis International. 2014 Jan; 18 (1):70-7. Available from: DOI:10.1111/hdi.12098. [18] Julius M, Hawthorne VM, Carpentier-Alting P, Kneisley J, Wolfe RA, Port FK. Independ- ence in activities of daily living for end-stage renal disease patients: biomedical and de- mographic correlates. American Journal of Kidney Diseases. 1989 Jan 1; 13 (1):61-9. [19] Painter P, Marcus RL. Assessing physical function and physical activity in patients with CKD. Clinical Journal of the American Society of Nephrology. 2013 May 7; 8 (5):861 -72. Available from: DOI: 10.2215/ CJN.06590712. [20] Cook WL, Jassal SV. Functional dependencies among the elderly on hemodialysis. Kidney International. 2008 Jun 1; 73 (11):1289-95. Available from: DOI:10.1038/ki.2008.62. [21] Mohamed SK, El-Fouly YA, El-Deeb MA. Im- pact of a designed self-care program on se- lected outcomes among patients undergoing [3] Shabila NP, Alhagbaker JM, Ali SS. Daily living activities among geriatric residents at geriatric homes in Erbil and Sulaima- niyah cities, Kurdistan Region. Zanco Jour- nal of Medical Sciences. 2017; 21(1):1619- 28. Available from: https:// doi.org/10.15218/zjms.2017.012. [4] Mlinaca ME, Fengb MC. Assessment of Activities of Daily Living, Self-Care, and Independence. Archives of Clinical Neuro- psychology. 2016;506–516. Available from: DOI:10.1093/arclin/acw049. [5] Williams LS, Hopper PD. Understanding Medical-Surgical Nursing. 2nd ed. USA, Philadelphia: F.A. Davis Company Publish- ing; 2003. p. 645-7. [6] Kopple JD, Kim JC, Shapiro BB, Zhang M, Li Y, Porszasz J et al. Factors affecting daily physical activity and physical performance in maintenance dialysis patients. Journal of Renal Nutrition. 2018; 25(2): 217–22. Available from: DOI:10.1053/ j.jrn.2014.10.017. [7] Atashpeikar S, Jalilazar T, Heidarzadeh M. Self-care ability in hemodialysis patients. Journal of Caring Sciences. 2012 May; 1(1): 31-5. [8] Johansen KL, Chertow GM, Ng AV, Mulli- gan K, Carey S, Schoenfeld PY, et al. Physi- cal activity levels in patients on hemodialy- sis and healthy sedentary controls. Kidney International. 2000 1st June; 57(6):2564- 70. Available from: DOI: 10.1046/j.1523- 1755.2000.00116.x. [9] Shukla B, Kaur A. Study to assess knowledge and attitude regarding self- care among patients undergoing hemodi- alysis in selected hospital of Punjab, India. JARS International Research Journal. 2012; 2 (1): 3-4. [10] Feinstein AR, Josephy BR, Wells CK. Scien- tific and clinical problems in indexes of functional disability. Annals of Internal Medicine. 1986 Sep 1; 105 (3):413-20. [11] Lawton MP, Brody EM. Assessment of old- er people: self-maintaining and instrumen- tal activities of daily living. The Gerontolo- gist. 1969 1st October; 9 (3): 179-86. [12] Singh S, Multani NK, Verma SK. Develop- ment and validation of geriatric assess- ment tools: A preliminary report from Indi- an population. Journal of Exercise Science and Physiotherapy. 2007 Dec; 3 (2):103. 12 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2021.01 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article Kidney International. 2010 Dec 1; 78 (11):1164-70. Available from: DOI:10.1038/ ki.2010.312. [31] Stack AG, Murthy B. Exercise and limitations in physical activity levels among new dialysis patients in the United States: an epidemio- logic study. Annals of Epidemiology. 2008 Dec 1; 18 (12):880-8. [32] Na L, Streim JE. Psychosocial well-being as- sociated with activity of daily living stages among community-dwelling older adults. Gerontology and Geriatric Medicine. 2017 Mar 21; 3 (1): 1-13. Available from: doi.10.1177/23337214177000. [33] Yu F, Chen Y, Mathiason MA, Wan Q, Lin FV. Cognitive and physical factors affecting daily function in Alzheimer's disease: A cross- sectional analysis. Nursing & Health Scienc- es. 2019 Mar; 21(1):14-20. Available from: DOI: 10.1111/nhs.12426. [34] Aucella F, Battaglia Y, Bellizzi V, Bolignano D, Capitanini A, Cupisti A. Physical exercise pro- grams in CKD: lights, shades and perspec- tives: a position paper of the “Physical Exer- cise in CKD Study Group” of the Italian Socie- ty of Nephrology. Journal of Nephrology. 2015 Apr 1;28 (2):143-50. Available from: DOI 10.1007/s40620-014-0169-6. [35] Mollaoglu M. Fatigue in people undergoing hemodialysis. Dialysis & Transplantation. 2009 Jun; 38 (6):216-20. [36] Muehrer RJ, Schatell D, Witten B, Gangnon R, Becker BN, Hofmann RM. Factors affecting employment at initiation of dialy- sis. Clinical Journal of the American Society of Nephrology. 2011 Mar 1; 6 (3):489-96. Available from: DOI: 10.2215/CJN.02550310. [37] Hallab A, Wish JB. Employment among pa- tients on dialysis: An unfulfilled promise. Clinical Journal of the American Society of Nephrology. 2018 January 18; 13 (1): 1-2. Available from: DOI: 10.2215/CJN.13491217. [38] Bağ E, Mollaoğlu M. The evaluation of self- care and self-efficacy in patients undergoing hemodialysis. Journal of Evaluation in Clini- cal Practice. 2010 Jun; 16 (3):605-10. Availa- blefrom:DOI:10.1111/j.1365- 2753.2009.01214.x. [39] Kamble DS, Shinde MB. Factors Affecting Quality of Life among Hemodialysis Patients. International Journal of Science an- dResearch. 2015; 6(1):572-6. hemodialysis. International Journal of Re- search in Applied. 2016; 4 (5):73-90. [22] Timby BK, Smith NE. Introductory medical- surgical nursing. 10th ed. Lippincott Wil- liams & Wilkins: 2010; P. 931. [23] Rahimi F, Oskouie F, Naser O, Sanandji ME, Gharib A. The effect of self-care on pa- tients undergoing hemodialysis in the Sanandaj Hospitals affiliated to Kurdistan University of Medical Sciences in 2016. Bali Medical Journal. 2017 Jan 1; 6 (3):684- 9. Available from: DOI:10.15562/bmj. [24] McCaleb A, Cull VV. Sociocultural influ- ences and self-care practices of middle adolescents. Journal of Pediatric Nursing. 2000 Feb 1; 15(1):30-5. [25] Caplin B, Kumar S, Davenport A. Patients' perspective of haemodialysis-associated symptoms. Nephrology Dialysis Transplan- tation. 2011 1st August;26(8):2656-63. Available from: DOI: 10.1093/ndt/gfq763. [26] Singh RG, Singh S, Rathore SS, Choudhary TA. Spectrum of intradialytic complications during hemodialysis and its management: a single-center experience. Saudi Journal of Kidney Diseases and Transplantation. 2015 Jan 1; 26 (1):168. [27] Gela D, Mengistu D. Self-management and associated factors among patients with end-stage renal disease undergoing hemo- dialysis at health facilities in Addis Ababa, Ethiopia. International Journal of Nephrol- ogy and Renovascular Disease. 2018; 11:329. Available from: http:// dx.doi.org/10.2147/IJNRD.S184671. [28] Minn WW. Enhancing patient safety in hemodialysis nursing care practice among nurses in the renal unit at the Defence Services General Hospital: a best practice implementation project. JBI Database of Systematic Reviews and Implementation Reports. 2014 Sep 1; 12 (9):467-88. Availa- ble from: DOI: 10.11124/jbisrir-2014-1368. [29] Xue H, Ix JH, Wang W, Brunelli SM, Lazarus M, Hakim R, et al. Hemodialysis access usage patterns in the incident dialysis year and associated catheter-related complica- tions. American Journal of Kidney Diseases. 2013 Jan 1; 61(1):123-30. Available from: http://dx.doi.org/10.1053/ j.ajkd.2012.09.006. [30] Johansen KL, Chertow GM, Kutner NG, Dalrymple LS, Grimes BA, Kaysen GA. Low level of self-reported physical activity in ambulatory patients new to dialysis 13 Erbil Journal of Nursing & Midwifery http://dx.doi.org/10.2147/IJNRD.S184671 http://dx.doi.org/10.2147/IJNRD.S184671 https://doi.org/10.15218/ejnm.2021.01 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article Available from: https:// doi.org/10.26719/2017.23.12.815 [49] Davenport A. Intradialytic complications during hemodialysis. Hemodialysis Interna- tional. 2006 Apr; 10 (2):162-7. [50] Asgari MR, Asghari F, Ghods AA, Ghorbani R, Motlagh NH, Rahaei F. Incidence and severi- ty of nausea and vomiting in a group of maintenance hemodialysis patients. Journal of Renal Injury Prevention. 2017; 6 (1):49. Available from: DOI: 10.15171/jrip.2017.09. [51] Mehmood Y, Ghafoor S, Ashraf MI, Riaz H, Atif SR, Saeed M. Intradialytic complications found in patients at a tertiary care hospital. Austin Journal of Pharmacology and Thera- peutics. 2016; 4 (1):107. [40] Thomas R, Kanso A, Sedor JR. Chronic kid- ney disease and its complications. Primary care: Clinics in office practice. 2008 Jun 1; 35 (2):329-44. Available from: DOI:10.1016/j.pop.2008.01.008. [41] Algarni RS. Exploring the Concept of Health -related Quality of Life for Patients with End-stage Renal Disease on Haemodialysis in the Eastern Region of Saudi Arabia. (Doctoral dissertation). The University of Manchester (United Kingdom)). 2014. Ac- cessed: 10th February 2020. Available from: https://www.semanticscholar.org/ paper/Exploring-the-concept-of-health- related-quality-of-Algarni/ ef304884f6e87594bf6c00509c3b10d5d3b 1e4a2 [42] Gutman, RA, Stead, WW, Robinson, RR. Physical activity and employment status of patients on maintenance dialysis. New England Journal of Medicine. 1981 Feb 5; 304 (6):309-13. [43] Anees M, Hameed F, Mumtaz A, Ibrahim M, Saeed KM. Dialysis-related factors affecting quality of life in patients on he- modialysis. Iranian Journal of Kidney Dis- eases. 2011 Jun; 5 (1):329-44. [44] Cheung AK, Sarnak MJ, Yan G, Dwyer JT, Heyka RJ, Rocco MV, et al. Atherosclerotic cardiovascular disease risks in chronic he- modialysis patients. Kidney International. 2000 Jul 1; 58 (1):353-62. [45] Mousa I, Ataba R, Al-Ali K, Alkaiyat A, Sa’ed HZ. Dialysis-related factors affecting self-efficacy and quality of life in patients on haemodialysis: a cross-sectional study from Palestine. Renal Replacement Thera- py. 2018 Dec; 4 (1):21. Available from: https://doi.org/10.1186/s41100-018-0162 -y. [46] Morfin JA, Fluck RJ, Weinhandl ED, Kansal S, McCullough PA, Komenda P. Intensive hemodialysis and treatment complications and tolerability. American Journal of Kid- ney Diseases. 2016 Nov 1; 68 (5):S43-50. Available from: http://dx.doi.org/10.1053/ j.ajkd.2016.05.021. [47] Schrier RW. Diseases of the Kidney & Uri- nary Tract. 8th ed. Volume 1. Lippincott Williams & Wilkins; 2007. Chapter 100. P. 2649-69. [48] Alhajim SA. Assessment of the quality of life in patients on haemodialysis in Iraq. Eastern Mediterranean Health Journal. 2017 Jan 1; 23 (12):815-20. 14 Erbil Journal of Nursing & Midwifery