Hrev_master Healthcare in Low-resource Settings 2024; volume 12(s1):xxx [Healthcare in Low-resource Settings 2024;12(s1):13048] [page 41] Significance for public health This study is the first of its kind to investigate the correlation between peer social support and family psychological resilience in caring for chronic kidney dis- ease patients receiving hemodialysis critically. The results show the importance for healthcare professionals to address the psychological well-being of families, enabling them to adapt and have resilience in supporting and caring for chronic kidney disease patients. Families with high psychological resilience are poised to experience improved quality of life and adherence to hemodialysis therapy. Healthcare in Low-resource Settings 2024; volume 12(s1):13048 The role of peer social support on family psychological resilience in caring for chronic kidney disease patients receiving hemodialysis Lilik Supriati,1 Muhammad Sunarto,1 Ikhda Ulya,1 Muhammad Rodli,2 Rendi Yoga Saputra,3 Renny Nova,1 Nur Hidaayah4 1Department of Nursing, Faculty of Health Sciences, Universitas Brawijaya, Malang, East Java; 2Institute of Science Technology and Health Hospital Dr. Soepraoen, Malang, East Java; 3Radjiman Wediodiningrat State Mental Hospital, Malang, East Java; 4Department of Nursing, Faculty of Nursing, Universitas Nahdlatul Ulama Surabaya, Surabaya, East Java, Indonesia Abstract Chronic Kidney Disease (CKD) is a disease that necessitates continuous Hemodialysis (HD) therapy, and families, as primary caregivers in Indonesia, play a crucial role in caring for CKD patients. However, HD therapy places a significant burden not only on patients but also on their families, requiring fostering fam- ily psychological resilience to mitigate such a burden. Although peer social support is an important external factor in chronic dis- ease, it is still underdeveloped. Therefore, this study aimed to explore the correlation between peer social support and family psychological resilience in caring for CKD patients receiving HD. This cross-sectional study used purposive sampling, engaging 134 families serving as caregivers for patients receiving HD ther- apy. The Berlin Social Support Scales (BSSS) and The Walsh Family Resilience Questionnaire (WFRQ) were adopted as instru- ments, and data were analyzed using univariate and Spearman tests. The majority of families reported high levels of peer social support (75,37%), predominantly originating from other members facing similar challenges related to caring for CKD patients. Additionally, a significant relationship was observed between peer social support and family psychological resilience (p-value<0.05), showing that higher levels of peer support corresponded to higher family resilience. In conclusion, there was a strong correlation between peer social support and family resilience in the context of caring for CKD patients. Healthcare professionals should inte- grate social support intervention by establishing social groups to enhance family resilience. Introduction The prevalence of Chronic Kidney Disease (CKD) is increas- ing,1 making it one of the most rapidly growing Non- Communicable Diseases (NCD) with significant mortality and morbidity burdens.2 Globally, kidney disease affects over 750 mil- lion individuals, as reported by global health authorities.2,3 According to the Basic Health Study in 2018, the prevalence of chronic kidney failure was 0.38%, accounting for 713,783 individ- uals in Indonesia. East Java Province ranks second nationally in terms of the highest number of chronic kidney failure cases, with nearly 113,045 individuals affected.4,5 Specifically, in Malang City, the prevalence of the disease exceeds 2,500 patients, a num- ber expected to rise due to the increasing cases of diabetes and hypertension.4 Patients with CKD need Hemodialysis (HD) therapy to sustain their lives,6 with the majority receiving long-term treatment and managing self-care behaviors to maintain a healthy lifestyle at home. However, the prolonged duration of care at home can lead to a sense of burden among families caring for HD patients. The burden arises from the continuous need for medical intervention and the extended treatment duration.7 Typically, chronically dis- eased patients receive care from an informal support system,8 with family caregivers playing a crucial role in the care. Caring for individuals with long-term kidney disease poses a psychological burden on families serving as primary caregivers at home due to the various challenges associated with HD.9 CKD poses a significant threat to the health, economic, and social well-being of affected individuals and their families.10,11 The burdens experienced by families include financial, physical, social, and psychological aspects. Social burden restrict families’ ability to socialize with relatives or friends, while physical burden lead to fatigue from the extensive time spent caring for HD patients. Psychological burden manifests as feelings of embarrass- ment, anger, and disappointment about the current situation. Additionally, the financial burden results in economic instability due to the considerable costs associated with HD.8,12,7 Families, as caregivers also encounter challenges in navigating various health and social care settings,8 seeking treatments, and managing the associated costs, leading to additional stress. Therefore, families require psychological resilience to cope with these challenges.9,12 Family resilience in caring for chronic disease has garnered atten- tion from analysts in recent years.10,13 Family psychological resilience serves as a strategy for fami- lies to navigate pressure, challenges, or conflicts arising from car- ing for HD patients, enabling them to overcome discomfort and pressure effectively.14,15 High resilience is essential for families caring for the patients, with positive resilience arising from high Non -co mmerc ial us e o nly self-confidence and belief.16 This resilience enables families to ful- fill their functions effectively and adapt positively to stressful sit- uations.17,18,19,20 Viewing family resilience from a relational per- spective acknowledges the interconnectedness of individuals with- in familial networks managing the complex demands of HD treat- ment.14 Resilience, influenced by both internal and external factors, is essential for families navigating the challenges of caring for HD patients.21 External encouragement, known as social support, plays a crucial role in aiding families to overcome the challenges. Social support includes various forms of attention, enthusiasm, apprecia- tion, acceptance, and assistance from multiple sources. Peer sup- port, a specific type of social support, provides a complementary approach to addressing patients’ emotional well-being and infor- mational needs.22 It comprises individuals with firsthand experi- ence of a condition sharing knowledge and experiences to support others facing similar health-related issues caring for CKD patients benefit from peer social support offered by individuals or families facing similar challenges.23 Families caring for CKD patients also benefit from peer social support provided by those experiencing similar challenges.24 Social support, recognized as an effective intervention, can manifest in various aspects, including emotional, appreciative, informational, and instrumental,25 nurturing hope among HD patients.26 Several reviews have shown that peer social support helps alleviate depression and burden while fostering a positive outlook for families.24,27 Support from families and friends plays a crucial role in coping with the advanced stages of chronic renal failure.10 However, investigations on the correlation between peer social support for families and resilience in caring for CKD patients remain limited. Materials and Methods Design This study used a cross-sectional design with an observational method. Sample The data collection was carried out from March to October 2023, engaging families caring for CKD patients receiving HD therapy at Lavalette Hospital in Malang City, East Java Province. The samples were families meeting the specific inclusion criteria, comprising, those caring for CKD patients receiving HD therapy for 1—5 years, aged at least 19 years old, cooperative, and profi- cient in Indonesian communication. A total of 134 families of CKD patients participated in this study, through the purposive sampling method. Ethical consideration This study received ethical clearance under number 6806/UN10.F17.10.4/TU/2023 from the Faculty of Health Sciences, Universitas Brawijaya, Indonesia. Data collection and procedures The research process commenced with licensing and obtaining ethical clearance. Detailed informed consent was obtained from each participant without coercion to participate in the study. Data were collected offline using a paper-based questionnaire tailored to each participants condition, and statistical analysis was performed using SPSS. The data input process consisted of editing to ensure completeness, coding for scoring and interpretation, and checking 4th International Nursing and Health Sciences Symposium Table 1. Family characteristics. Characteristics Category Frequency (f) Percentage (%) Age 19-44 years 47 35.1 45-59 years 63 47.0 ≥ 60 years 24 17.9 Gender Male 50 37.3 Female 84 62.7 Education No Education 1 0.7 Elementary school 18 13.4 Junior high school 23 17.2 Senior high school 57 42.5 University 35 26.1 Work Working 60 44.8 No working 74 55.2 Economy status Under the minimum wage for work 117 87.3 Above the minimum wage for work 17 12.7 Family relationship with patients Parents 17 12.7 Husband/wife 78 58.2 Grand parents 1 0.7 child 30 22.4 Grand child 2 1.5 Siblings 6 4.5 Distance of home to hospital Near (10 kilometers) 69 51.5 Far enough (10-20 kilometers) 34 25.4 Far (more than 20 kilometers) 31 23.1 Length of time for caring patients 1-2 years 85 63.4 3-5 years 49 36.6 [page 42] [Healthcare in Low-resource Settings 2024;12(s1):13048] Non -co mmerc ial us e o nly for missing data and errors. Univariate and bivariate tests were conducted for data analysis. An instrument for data collection The Walsh Family Resilience Questionnaire (WFRQ) was adopted to assess family psychological resilience, comprising the indicator of belief systems, organizational patterns, and communi- cation/problem-solving. The questionnaire consisted of 26 ques- tions, rated on a scale from 1 (Strongly disagree) to 5 (Strongly agree), with a total score range of 26 to 130. Similarly, the Berlin Social Support Scales (BSSS) questionnaire was used to evaluate peer social support, covering emotional, instrumental, apprecia- tion, and informational. The questionnaire consisted of 12 ques- tions, also rated from 1 to 5, resulting in a total score range of 12 to 48. Both instruments received rigorous testing for reliability and validity. The WFRQ questionnaire showed validity with a value range of r = 0.493-0.948 and a reliability score of 0.957. The BSSS had a reliability value of 0.941 and validity ranging from 0.521– 0.915. Data analysis The collected data were subjected to screening for missing items, followed by the computation of total scale scores for peer social support and family psychological resilience. The score of each variable was categorized as high (96-130), sufficient (61-95), and low (26-60). Peer social support was categorized to be high (36-48), medium (24- 35), and low (12-23). Statistical analysis was performed through univariate and Spearman rank correlation, using SPSS version 25. Results and Discussion Table 1 presented the characteristics of the participants, indi- cating that the majority of them fell within the 45-59 age range (47%) and had a senior high school education background (42,5%). A significant portion of the participants were unemployed (55,2%) and the majority had incomes below the minimum wage (87,3%). All of them had a familial relationship with the patients, predominantly as spouses. Most of the participants resided in close proximity to a hospital (69%), with an average distance of around 10 kilometers. Additionally, the duration of caregiving at home ranged from 1- 2 years for the majority (63,4%). In Table 2, the independent variables were described, suggest- ing that the emotional support received by families in caring for CKD patients was largely categorized as high (76.11%), with only a small percentage falling into the low category (3.73%). Meanwhile, instrumental, appreciation, and information support received by families were mostly at high levels (79.10%, 85.07%, and 85.3%, respectively). The results showed that peer social sup- port enjoyed by families caring for CKD patients receiving HD was generally at a high level. Table 3 presented the description of dependent variables, indi- 4th International Nursing and Health Sciences Symposium [Healthcare in Low-resource Settings 2024;12(s1):xxx] [page 43] Table 2. Distribution of independent variables. Variable Category Low Medium High f % f % f % Emotional support 5 3.73 14 12.1 102 76.11 Instrumental support 6 4.47 10 8.6 106 79.10 Appreciation support 2 1.49 5 4.3 114 85.07 Informational support 2 1.49 15 12.9 99 85.3 Peer social support 8 3.73 25 18.65 101 75.37 Table 3. Distribution of dependent variables Variable Category Low Medium High f % f % f % Belief systems 5 0.9 8 2.6 121 96.6 organization patterns 7 1.7 12 9.5 115 88.8 Communication/problem-solving 8 2.6 10 5.2 116 92.2 Family Psychological Resilience 9 6.71 14 10.44 111 82.83 Table 4. Correlation peer social support and psychological family resilience Peer social support Family psichological resilience Total p r correlation Low Medium High n % n % n % n % Low 5 2.58 2 0.86 0 0 7 3.44 0.000 0.584 Medium 0 0 5 2.58 14 9.46 19 12.04 High 0 0 2 0.86 97 83.42 108 84.24 Uji Spearman’s rho r= 0.584** p-value 0.000. **. Significant. Non -co mmerc ial us e o nly cating that the indicators of family resilience, specifically belief systems, predominantly fell within the high-level category (96.6%). Additionally, organizational patterns and communica- tion/problem-solving fell into the high level for the majority (88.8% and 82.83% respectively). The results showed that family psychological resilience in caring for CKD patients receiving HD tended to be predominantly at a high level. In Table 4, a significant relationship between peer social sup- port and family psychological resilience (p-value < 0.05) was observed, with a strong positive correlation of R = 0,584. This implied that higher levels of peer social support were associated with better family psychological resilience in caring for CKD patients receiving HD. This study aimed to measure the correlation between peer social support and family psychological resilience in caring for CKD patients receiving HD. The results showed that peer support received by families caring for CKD patients fell within the high category. The analysis was in line with previous reviews indicating the importance of peer social support from friends or families fac- ing similar challenges.27 Peer support covered a range of support- ive actions, including understanding, attention, and affection, which individuals could access through their social relationships with others, groups, or communities, thereby enhancing the quality of life.6,7 Families encountering similar challenges of caring for CKD patients often showed mutual care and empathy when interacting with other families in hospital settings.23 Sharing experiences and information regarding caring for the patients receiving HD could alleviate stress and family burdens. Social support covered four types, appreciation, instrumental, emotional, and informational. The predominant type of social support received by families in this study was appreciation. Chronic diseases such as breast cancer and CKD require complex treatment due to their inherent uncertainty. However, emotional support from peers facing similar diseases was crucial in helping families and patients manage psychological challenges.28-30 Appreciation support, identified as the most com- mon form of support received by 114 families (85,07%), consisted, of showing positive appreciation, encouragement, and approval of ideas or individual feelings. Families reported receiving consistent encouragement and support from individuals around them, which corroborated with previous reviews indicating high-esteem support characterized by positive reinforcement, constructive criticism, and appreciation for efforts made, thereby fostering motivation.31 Appreciation support could build individuals’ self-esteem, leading to greater respect from others.32 Patients receiving HD faced mental and health challenges, which also affected their families.10 In Indonesia, families played a crucial role as primary caregivers, with the majority of participants having a relationship with CKD patients as spouses (58,2%). This was in line with the investigation conducted in other Indonesian hospitals, where “caregivers” included spouses, children, grand- children, nieces, nephews, and acquaintances. Families served as the primary caretaker and provided support for self-management and other necessities.33 Caring for a chronic disease, particularly CKD comprised managing the demands of the disease and coping with the associated stress.17 The results showed the majority of families had high resilience (82.83%), attributed to the fact that most of them (63.8%) had been caring for CKD patients for 1-2 years. The analysis was in line with previous reviews suggesting that spending more time caring for the patients enabled families to become more adaptable.21 As caregivers provided care over an extended period, they tended to experience fewer emotional prob- lems and develop better-coping mechanisms. Consequently, fami- lies with high resilience tended to experience lower levels of depressive symptoms.15,21 Family resilience covered three indicators, including belief systems, organizational patterns, and communication and problem- solving processes.15,19 The results showed that the most commonly experienced type of resilience among families was belief systems (96.6%). Belief systems comprised the family’s positive interpre- tation of events, such as maintaining optimism about the future or having faith in God.19 Families with good knowledge, an opti- mistic outlook, and strong religious beliefs or confidence could reduce feelings of anxiety and enhance their readiness to care for CKD patients at home.15,7 This was in line with previous reviews indicating that families managing chronic disease strive for self- adjustment by adapting to uncertainty and overcoming family 4th International Nursing and Health Sciences Symposium Correspondence: Lilik Supriati, Department of Nursing, Faculty of Health Sciences, Universitas Brawijaya, Jl. Puncak Dieng, Kunci, Kalisongo, Kec. Dau, Malang, East Java Indonesia,. Tel.: +62341569117, Fax: +62341564755 E-mail: liliks.83@ub.ac.id Key words: chronic kidney failure; family social support; hemodialysis; psychological resilience Contributions: LS and MS significantly contributed to the conceptualiza- tion, study design, and data collection. IU and RN conducted data analy- sis and interpretation. NH, MR, and RY were engaged in manuscript drafting. LS and MS critically revised the manuscript for important intel- lectual content and provided final approval for publication. Conflict of interest: the authors declare no potential conflicts of interest. Funding: this study received funding from the Research Institutes and Community Service (BPPM) Faculty of Health Science, Universitas Brawijaya. The authors deeply appreciate the support received for the article. Ethics approval: this study received ethical clearance under number 6806/UN10.F17.10.4/TU/2023 from the Faculty of Health Sciences, Universitas Brawijaya, Indonesia. Clinical trials: not applicable. Conference presentation: part of this article was presented at the 4th International Nursing and Health Sciences Symposium, from 27th-28th of October 2023, Universitas Brawijaya, Malang, East Java, Indonesia. Acknowledgment: the authors thank all participants, and also extend their appreciation to the Research Institutes and Community Service (BPPM) Faculty of Health Science, Universitas Brawijaya, for funding this study. They deeply acknowledge everyone who contributed to the completion of the analysis. Received: 4 November 2023. Accepted: 8 June 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12(s1):13048 doi:10.4081/hls.2024.13048 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 44] [Healthcare in Low-resource Settings 2024;12(s1):13048] Non -co mmerc ial us e o nly problems related to disease.21,34,29 The analysis showed a significant relationship between peer social support and family psychological resilience (p-value <0.05), suggesting that higher levels of peer social support corresponded to increased family resilience. The results were in line with previ- ous reviews indicating that peer social support served as a predic- tor of quality of life, not only for patients but also for their families. Peer support played a crucial role in fostering relationships and preparing individuals for uncertainty.23 Moreover, it motivated families to support patients in adhering to therapy regimens.1,27 Positive peer support and family resilience were associated with improved adherence to functional exercise, leading to a reduction in symptom burden. The results contributed to the understanding of the positive psychological and social implications of family resilience.21 Conclusions In conclusion, peer social support and family resilience in car- ing for CKD patients receiving HD predominantly fell into the high category. The strong correlation between peer social support and family resilience showed the importance of enhancing peer social to support family psychological resilience in caring for CKD patients. 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